Telehealth is the use of electronic information and telecommunications technologies to support remote clinical health care, patient and professional health-related education, public health, and other health care delivery functions. A narrower concept, telemedicine, refers to clinical services that are provided remotely via telecommunications technologies. Some sources use the two terms interchangeably, and there is no consensus among federal programs and among health care providers on the definition of either term.
Federal involvement in telehealth is varied. As of 2014, more than 20 federal agencies were engaged in some aspect of telehealth. For example, in FY2015, the Department of Veterans Affairs (VA) was the largest telehealth provider in the federal government, providing 2.1 million telehealth consultations to some 677,000 veterans. In contrast, the Medicare (Part B) program, covering more than 52 million beneficiaries, the number of telehealth visits increased fivefold from 38,000 telehealth consultations (or visits) in 2009 to 192,692 in 2015. The VA, the Centers for Medicare and Medicaid Services (CMS), the Institute of Medicine, and other stakeholders have identified barriers associated with the use of telehealth, notably that some telehealth modalities have a stronger evidence base than others. Furthermore, according to the Agency for Healthcare Research and Quality (AHRQ), key issues requiring additional research are the impact of telehealth on individual and population health, and on moving away from traditional fee structures toward rewarding clinicians for value versus volume of care.
Telehealth has been an active legislative issue thus far in the 114th Congress. For example, in February 2016, bipartisan legislation was introduced to expand telehealth reimbursement for remote patient monitoring under the Medicare program. In December 2015, the Senate Committee on Finance published options for expanding telehealth utilization for Medicare beneficiaries with chronic conditions. H.R. 6, the 21st Century Cures Act (as passed by the House), would require CMS and the Medicare Payment Advisory Commission to submit programmatic information to Congress on telehealth. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10) includes a provision that encourages the use of telehealth as an element in the new Merit-Based Incentive Payment System and requires the Government Accountability Office to study telehealth and its use under the Medicare program.
This report identifies telehealth activities at select federal agencies along with an assessment of the evidence regarding the potential impact of telehealth on health care access, cost, and quality.
Telehealth is "the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration."1 Videoconferencing, store-and-forward imaging, and remote monitoring are some examples of telehealth applications.2 Though "telehealth" may refer to non-clinical services that are provided remotely, such as training, administrative meetings, and continuing education, some individuals may use the term "telemedicine" to describe the use of telecommunications technologies in clinical situations that include patient diagnosis, prescriptions, and treatment at a distance.3
The 114th Congress has witnessed the introduction of a number of telehealth-related pieces of legislation that address a wide range of issues that have the potential to impact access to, along with the cost and quality of care under various federal programs, including Medicare.
In recent years, the federal government has embarked on various initiatives to increase access to telehealth services (as well as to improve the underlying technological infrastructure that supports telehealth) at more than 20 federal agencies.4 Examples of this agency activity include:
Trends in telehealth access, utilization, and innovation indicate that sustained interest is likely among health insurance plans, institutions, and major decisionmakers. For example, market analysts predict that:
Though providers are using telehealth to overcome barriers to health care access created by geography and time, the evidence-base for its use, including issues related to cost and quality, are strong in some areas and weak in others. For example, the Agency for Healthcare Research and Quality (AHRQ) reports that there is evidence that telehealth is effective for certain types of chronic conditions (such as diabetes, heart disease and conditions such as behavioral health).11 Also, AHRQ describes how telehealth applications may lead to improvements in health outcomes, and reductions in health care costs, such as fewer hospitalizations and fewer emergency room visits, but these findings have not been tested for all telehealth settings.12 On the other hand, more robust evidence is not yet available in relation to telehealth and various medical specialties according to AHRQ and the Institute of Medicine (IOM).13 Among the questions that are in need of more evidence: What is the patient telehealth experience regarding safety, effectiveness, timeliness, and overall access to health care? Which cost and quality measures support telehealth applications in primary care and urgent care populations, and which are cost drivers for public health insurance programs, such as Medicare and Medicaid?
This report describes telehealth activities at selected federal agencies, and the evidence available to assess telehealth through the lenses of health care access, cost, and quality.14
In this report, access refers to telehealth tools and systems that address behavioral, social and, environmental determinants of health and deliver high quality care; cost is associated with telehealth interventions that impact the cost of health care for individuals, families, employers, and government; and quality is associated with telehealth initiatives that improve the overall quality of care by resulting in health care that is more patient-centered, reliable, accessible and safe.15 Telecommunications16 systems along with federal and state licensure policies also impact access, cost and quality, but their discussion is beyond the scope of this report (telecommunications issues are briefly discussed in Appendix D).
Current laws, policies, and guidance present a range of descriptions for telehealth and the related term telemedicine, reflecting a need for clarity and distinction.17 For example, the Office of the National Coordinator for Health Information Technology (ONC) distinguishes between telemedicine and telehealth, with telemedicine being a function of interactions that involve clinical decisionmaking. The Agency for Healthcare Research and Quality (AHRQ) makes a distinction among technologies that support telehealth, noting that the technologies are not treatments in and of themselves but are the means for delivering health care in different formats, such as remote patient monitoring, videoconferencing, Internet applications, and devices.18 Within the VA, the Veterans Health Administration (VHA) notes that telehealth technologies may include single or combined uses of: videoconferencing, mobile technologies, store-and forward technology (or asynchronous communication).19 CMS, under the Medicare program, acknowledges that some health plans under its Medicare Advantage (MA) program conduct health services by telephone, over the Internet, or via telemonitoring for selected Medicare beneficiaries.20 Under the Medicaid program, states use the terms "telemedicine" or "telehealth" interchangeably. Some state laws explicitly define the terms, and place restrictions within the definition, such as the exclusion of email, phone, or fax from the definition. Other states may use "telehealth" to reflect a broader definition, and use "telemedicine" to define the delivery of clinical services.21
These and other distinctions are important not merely for semantic reasons but because they have implications for federal policies that impact access, cost and/or quality. For example, the Medicare statute22 delineates boundaries for "telehealth" reimbursement, and the regulation specifies the conditions under which Medicare makes a payment to a provider for services delivered via telehealth technologies.23 An acknowledgment of these differences, which may or may not result in uniformity, may be significant for policy decisions that involve telehealth and telemedicine.
FedTel, a workgroup supported by the Health Resources and Services Administration (HRSA), consists of 26 federal agencies that invest in, or maintain an interest in, various telehealth activities.24 This section describes telehealth at three federal agencies that are directly involved with telehealth and patient care, and one agency that oversees the nation's largest program for health insurance financing. As noted earlier, issues such as the telecommunications infrastructure that supports the delivery of telehealth services (see Appendix D) or legal matters such as state licensure portability for providers of telehealth services, while important, are beyond the scope of this report which is focused solely on health policy, financing, and service delivery related matters.
Various federal agencies use telehealth services to help in providing direct patient care. For example, the VA, DOD, and the Indian Health Service (IHS) provide health care via telehealth to veterans, military beneficiaries, and underserved tribal populations, respectively.25 This section summarizes examples of telehealth activities in these three federal agencies with substantial telehealth experience. A major caveat analysts of telehealth raise is that it may not be appropriate for all consumers or providers in situations where certain clinical, technological, and environmental factors dictate prudence on the part of the provider. For example, in its Practice Guidelines for Live, On Demand Primary and Urgent Care, the American Telemedicine Association (ATA) urges providers to "exercise their professional judgment when deciding whether or not to use telemedicine, taking into account the patient condition, mitigating circumstances, available resources, and their own comfort level and expertise in using telemedicine." For example, where diagnostic interventions cannot be supported by high quality evidence, providers "shall use their professional judgment, experience and expertise in making such decisions. Conditions for use of telemedicine are likely to change to reflect new evidence from future research and the evolution of the enabling technology." In addition, some physical environments do not support telehealth visits, specifically where there is a lack of privacy, inappropriate lighting, or other distractions.26 The ATA encourages providers to follow these practice guidelines and guidelines published by other organizations, including governmental agencies and professional entities.27
The VA operates the largest integrated health care delivery system in the United States. It administers health services through 151 Medical Centers, 300 Vet Centers, 820 Community-based Outpatient Clinics (CBOCs), 135 Community Living Centers, 6 Independent Outpatient Clinics, and 103 Residential Rehabilitation Centers throughout the 50 states, U.S. States territories, and the Philippines.28 In FY2015, the VA employed 298,546 medical care and research professionals.29 In FY2015, the VA served some 6.8 million unique patients, dependents, and survivors.30
Telehealth technologies used in VA health care include the following:
According to the VA, telehealth is significant for the populations it serves because health providers can use the technology to reach rural and remote populations, thereby increasing access to care and reducing the time and cost required to travel to health care facilities.34 The VA's own data from 2014 indicates that mental illnesses are among the major health concerns for veterans, with Post-Traumatic Stress Disorder (PTSD) ranking the highest.35 Telehealth technologies support veteran's use of medical apps to help them manage PTSD by accessing tools for symptom-tracking and self-assessment.36
A number of studies provide performance data on VA telehealth systems and their impact on veterans' health, cost of care, and overall patient experience.37 On access, veterans and their providers exchange health information and services through integrated networks such as the Veterans Health Information Systems and Technology Architecture (VistA);38 My Health eVet;39 and Blue Button.40 In 2015, VA providers delivered 2.1 million telehealth consultations to more than 677,000 veterans via videoconferencing, home telehealth, and store-and-forward telehealth that were provided through one or more of those systems. According to the VA, 45% of the veterans receiving telehealth services live in rural areas. In 2017, VA expects to deliver telehealth-based services to nearly 762,000 veterans (an increase of 12.5%).41 Evidence indicates that such access is associated with reductions in hospital admissions, and high rates of patient satisfaction among the veteran population.42 For example, during FY2012, the VA reported that its home telehealth program, consisting of 119,535 veterans resulted in reduced hospital admissions by 38%, and in savings of $1,999 per year per patient.43
The DOD's Military Health System (MHS) provides health care to more than 9.7 million beneficiaries through a health care network consisting of 56 hospitals, 365 clinics, and other facilities worldwide. It operates globally and employs more than 86,000 military personnel and nearly 58,400 civilians.44
DOD's current inventory of electronic health record systems (or legacy systems) includes, among others, inpatient health record systems, outpatient systems, and telehealth components.45 DOD recognizes the "need for enhanced EHR support of telehealth," and such collaboration is a goal of military health system EHR modernization efforts.46
According to the U.S. Army's Surgeon General, Army telehealth systems enable health services to be accessed across the largest geographic area of any telehealth system in the world: Army clinicians can reach service personnel and families to provide health care in multiple medical specialties, across 18 time zones and in over 30 countries and territories.47 DOD telehealth exchanges occur over telecommunications media that range from telephones to email.48
In FY2013, the MHS provided approximately 30,000 telehealth encounters through live videoconferencing. Nearly all of these encounters were for patients with psychological health-related issues, with PTSD accounting for approximately 20% of all mental telehealth consultations.49 Additional examples of telehealth initiatives within the DOD include the following:
Within the context of patient care, telehealth has increased collaborative opportunities for DOD health providers in pain management through the Project Extension for Community Health Outcomes (ECHO) initiative. Between January 2010 and December 2012, Project ECHO incorporated case-based learning, demonstrations, and teaching through an inter-professional continuing education program for 136 pain clinics and 763 individuals from 191 sites in rural and underserved communities. Project ECHO evaluated approaches to learning and professional practice, and found that the telementoring model (1) closed the knowledge gap in pain education; and (2) served as a model for inter-professional collaborative practice, thereby impacting improved care experiences (or quality) for soldiers and veterans.52 Currently, Project ECHO serves all military service units and the VA, specializing in traumatic brain injury, behavioral health, complicated diabetes, and other conditions.53
However, within the military, mental health conditions such as PTSD are associated with a "high prevalence of stigma." Active-duty servicemembers are concerned about possible adverse effects of mental-health diagnoses and treatment on career advancement. They are reluctant to seek care for mental-health problems due to concerns about the privacy of their health information. According to IOM, telemedicine may address health care access for active duty members, but more needs to be done to determine its acceptance and efficacy.54
The Indian Health Service (IHS) is a federal health system that coordinates health care and disease prevention services for approximately 2.2 million American Indians and Alaska Natives (AI/AN) through a network of more than 679 hospitals, clinics, and health stations on or near Indian reservations.55 The IHS, Indian Tribes, or Tribal Organizations manage these facilities, which are predominantly located in rural settings. The IHS provides a wide range of clinical, public health, and community services primarily to members of 566 federally recognized tribes in 35 states. The IHS has approximately 15,369 employees, including 2,504 nurses, 737 physicians, 462 engineers, 132 sanitarians, 747 pharmacists, and 271 dentists. In addition, various allied health professionals, such as nutritionists, health administrators, and medical records administrators are IHS employees.56
Because many AI/AN populations typically reside in locations where they have little or no access to public transportation and must travel considerable distances to health facilities, telehealth has provided an alternative means to accessing health services in these often isolated communities. IHS beneficiaries receive telehealth services through various telecommunications systems that are set up, in part, through federal interagency collaborations and private networks. The IHS and the VA provide health care to veterans through integrated delivery systems that include VA clinical care sites.57 The following highlights are for telehealth activities within IHS systems (two of which are coordinated with VA and DOD):
This section describes Medicare65 and Medicaid66 reimbursement policies associated with telehealth. It also describes evolving health reforms that are incorporating payment models and systems that focus on improvements in population health, reductions in health costs, and enhancements in quality. This section does not provide historical background on telehealth reimbursement policies under Medicare or Medicaid programs, which are found elsewhere.67
Medicare is a federal entitlement program that provides a wide range of health care benefits to nearly 55 million seniors and certain individuals with disabilities at an annual cost of roughly $632 billion (in FY2015).68 Medicare provides benefits in the form of health insurance payments to providers who deliver services to beneficiaries. Medicare payments for health services are organized mainly through four parts: Part A (hospital insurance), Part B (physician services), Part C (managed care), and Part D (prescription drugs).69 Telehealth policies under Medicare Part B, Part C, and Part D70 are the subjects of this section.
Further, the Center for Medicare and Medicaid Innovation (CMMI),71 awards grants to eligible providers for demonstrations and innovative projects, which include telehealth and related services.72 Regarding telehealth, CMMI funds various health care payment and service delivery models, some of which incorporate telehealth into their design, such as Accountable Care Organizations (ACOs)73 and Bundled Payment for Care Improvement (BPCI) Initiatives.74
Medicare Part B reimburses physicians and other providers for medically necessary services and preventive services, such as those needed to diagnose or treat a medical condition and meeting accepted standards of medical practice. These services are typically provided face-to-face with the patient. In some instances, Part B pays if the services are provided via telehealth, in which the patient is at one location (referred to as the originating site) and the provider is at another location (referred to as the distant site).
The Medicare Fee-For-Service (FFS) Program (known as Original Medicare) is the basis for telehealth payments under Medicare Part B.75 The provider receives the same reimbursement as (s)he would have received had the services been furnished face-to-face. The originating site, where the patient is located, receives a nominal fee.76
Medicare telehealth coverage is subject to several limitations. The FY2015 Medicare Part B final rule77 identifies the following eligibility requirements for telehealth coverage under Medicare Part B:
In CY2009, Medicare Part B reported 38,000 telehealth visits,79 but according to CMS, telehealth expenditures were not reported for that year. Six years later, in CY2015, the total number of telehealth visits increased by more than fivefold to 192,692 for which physicians and other professionals received nearly $18 million.80 In comparison, in FY2014, total Part B expenditures for physician fee schedule services amounted to $69.2 billion.81 Telehealth reimbursement represents a tiny fraction of overall Medicare spending, partly because provider adoption has been "modest."82
While Part B pays physicians (and others) directly for the services they furnish to Medicare beneficiaries, Medicare Advantage (MA) plans offered by private companies under Part C are paid a fixed amount (or capitated monthly payment) each month to provide a suite of medical services to beneficiaries. Telehealth services are not required services offered under Part C, but MA plans are free to make available a variety of telehealth services to their enrollees, subject to general CMS guidelines. MA payments are determined through a comparison of a plan's estimated cost and the maximum amount Medicare will pay a plan.83 To date, MA plans have delivered telehealth services to beneficiaries via telemonitoring, web/phone-based technologies, and nursing hotlines.84 Given the optional nature of telehealth services under Part C, total Part C telehealth expenditures are not known. Total expenditures for Medicare Part C in 2014 amounted to $85.7 billion.85
Medicare Part D provides coverage of outpatient prescription drugs to Medicare beneficiaries who choose to enroll in this optional benefit through a Medicare Advantage Prescription Drug (MAPD) plan or a Prescription Drug Plan (PDP).86 The Medication Therapy Management (MTM) program is a system of coordinated pharmacy care under Part D for patients with multiple medical conditions who may be seeing a series of practitioners.87 As required for the coordinated care requirement, Part D plans must include periodic medication reviews, patient consultation and education.88 Annual medication reviews must be conducted either in-person or via telehealth consultations. However, discrete data on Part D telehealth benefits, providers, utilization, or cost are unavailable.89 Of interest, AHRQ has funded evidence-based research on the use of health information technology to improve quality of care within an MTM program.90 In FY2014, total Part D expenditures for prescription drugs amounted to $77.7 billion.91
Telehealth is a focus for selected demonstrations through Medicare, and innovation awards through the CMMI.92 Several of these projects and awards are generating evidence on telehealth access, cost, and quality. For example:
Recent legislative and regulatory activity is likely to result in more telehealth-related changes in Medicare. For example, the Medicare Access and CHIP Reauthorization Act (MACRA)100 established a new Merit-Based Incentive Payment System (MIPS). Under MIPS, beginning on January 1, 2019, Medicare providers will be required to comply with an alternative payment system founded on performance standards, composite performance scores, and incentive payments.101 The MIPS would apply a new set of measures and activities, including clinical practice improvement activities, to determine whether a provider qualifies for an incentive payment. Telehealth and remote monitoring are explicitly identified as examples of clinical practice improvement activities.102 MIPS implementing regulations are expected to be published in early 2016.
Earlier, in 2015, CMS published a final rule that qualifies "telehealth" and "remote patient monitoring" as two types of technologies among other tools that an ACO is permitted to use for the purpose of improving care coordination for Medicare beneficiaries.103 Also, in 2015, CMS announced that a "Next Generation ACO Model" would offer greater opportunities to coordinate care, including an expansion in the eligible settings where Medicare patients can be seen (or originating sites).104 Under the BPCI initiative, awardees may expand the use of telehealth services for beneficiaries through a waiver of Medicare payment policy. Awardees may provide telehealth services in any area (i.e., beyond those originating sites specified in Section 1834(m)(4) of the SSA). CMS has funded some telehealth studies through Medicare demonstrations, but results are mixed. Some studies show little or no evidence for telehealth cost savings, patient satisfaction and quality improvements,105 but others show some evidence that telehealth is beneficial to some aspects of the care delivery process, such as reduced hospitalizations, or improved patient experience.106
Medicaid is a joint federal-state program that finances the delivery of primary and acute medical services, as well as long-term services and supports, to an estimated 65million people. In CY2014, total payments for Medicaid services amounted to a cost of $494 billion, with the federal government paying $299 billion, or about 60% of the total.107
State Medicaid programs must follow federal requirements to receive federal matching funds but they have flexibility to design programs that meet a state's unique needs. States decide whether to provide telehealth and the type of telehealth services they will authorize for payment. This flexibility results in significant program variation across state Medicaid programs.108
Specifically, state Medicaid programs may decide on (1) the type of telemedicine service (equipment) to cover; (2) the types of telemedicine providers that may be covered and reimbursed; (3) how much to reimburse for telemedicine services, as long as such payments do not exceed federal upper payment limits; and (4) other conditions for payment.109
The text box summarizes states' policies for telemedicine equipment under Medicaid.
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Medicaid Telemedicine: State Policies Related to Type of Equipment In July 2015, the Center for Connected Health Policy (CCHP) completed a 50-state survey of state telehealth laws and Medicaid program policies. CCHP reported the following:
Source: Center for Connected Health Policy, Telehealth Medicaid & State Policy, accessed January 2016, http://cchpca.org/state-telehealth-laws-and-reimbursement-policies-report. Note that CCHP's work is funded in part by HRSA. |
Although many studies have been published on the quality of telehealth activities under the federal Medicare program, fewer studies have been published on state Medicaid programs. In addition, the few that are available report mixed results in, and take place in, variable care settings making comparability and transferability of findings difficult.110
There is growing use of and payment for telehealth-related services among a number of federally funded health programs – at the VA, DOD, the IHS, and by the Medicare program to name a few. All have been adopters (or payers) of various technologies and services to aid in the delivery of care to their respective patient populations. However, despite the level of interest and evidence that telehealth is a viable vehicle for delivering certain services to some populations, there remain a number of issues where evidence is insufficient to address key issues related to access, quality and cost of care.
The issues are often inter-related since how much a program or service may cost is related to how accessible a program or service is to the target population. If a service significantly increases the utilization of certain services, the question arises as to what is the downstream impact on the costs of care within a particular program. Some may argue that earlier interventions and diagnoses using telehealth could help to avoid major expenses in the future by better managing chronic conditions. Conversely, others may argue that increasing access will only add more spending and not less to an already expensive health care system by making such services more readily available to beneficiaries and consumers. More research is needed in different programs and settings to better inform questions of the impact of increasing access to care via telehealth on cost effectiveness and cost savings when telehealth services are employed.
Similarly, the quality of telehealth services needs additional study for a variety of services, programs, and populations. Is the quality of care and the outcomes associated with that care of greater, lesser or equal value when compared to traditional, brick-and-mortar care? There will be no single, one-size fits all answer to issues of quality. But additional research is needed to answer questions about the impact of these programs on key measures of quality, particularly at a time when there are increased calls to expand the use of telehealth across a number of federal programs as well as efforts to more directly tie reimbursement to quality/performance outcomes.
Finally, issues of uniformity in terminology could be the subject of further exploration. Specifically how the terms "telehealth" and "telemedicine" are used across federally funded health programs and if any differences in definitions result in problems associated with data collection, evaluation, and payment.
Appendix A. Definitions of Related Terms
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Distant site or hub site. Location where the physician or other licensed practitioner delivering the service is located when the time the service is provided via a telecommunications system (Source: Centers for Medicare and Medicaid Services (CMS), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html). Originating site or spoke site. Location of the patient when the service is being delivered via a telecommunications system (Source: CMS, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html). Mobile health or m-health. Software programs that run on smartphones and other mobile communication devices, which can also be accessories that attach to a smartphone or other mobile communication devices, or a combination of accessories and software. They are regulated as medical devices. Consumers can use both mobile medical apps and mobile apps to manage their own health and wellness, such as to monitor their caloric intake for healthy weight maintenance (Source: FDA, Mobile Medical Applications, http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ConnectedHealth/MobileMedicalApplications/default.htm#a). Remote consultations, clinical video consultations (or remote patient monitoring). Setting where the provider has a live, real-time clinical encounter with a patient over a distance for the purpose of examining or providing treatment to the patient (Source: Veterans Administration (VA), What is Telehealth? http://www.telehealth.va.gov/). Store-and-forward. Conditions where a health provider collects medical data, stores them, and then forwards them to be interpreted by a provider later on (Source: Veterans Administration (VA), What is Telehealth? http://www.telehealth.va.gov/). Telehealth encounter or telehealth consultation. Conditions where a provider provides clinical services to a patient over a distance using advanced telecommunications technologies (Source: Health Resources and Services Administration, Glossary, http://www.hrsa.gov/ruralhealth/about/telehealth/glossary.html). Telehealth services. Under Medicare Part B, conditions that involve provision of a health care benefit to a patient using telehealth equipment to convey the benefit. Although the state-based Medicaid program models its definition of telemedicine on Medicare's definition of telehealth services, the federal Medicaid statute does not recognize telemedicine as a distinct service (Source: 42 C.F.R. §410.78). |
FedTel consists of representatives of federal agencies, or departments and programs within those agencies, with an interest or activity in telemedicine. The Health Resources and Services Administration (HRSA), within the Department of Health and Human Services (HHS), coordinates FedTel. The following is a list of current members.
Agency for Healthcare Research and Quality (AHRQ)
Centers for Disease Control and Prevention (CDC)
Centers for Medicare & Medicaid Services (CMS)
Department of Agriculture (USDA)
Department of Labor (DOL)
Department of the Army (Telemedicine & Advanced Technology Research Center [TATRC])
Department of the Army (Army Medical Department (AMEDD))
Department of the Navy National Center for Telehealth & Technology (T2)
Department of Transportation (DOT)
Department of Veterans Affairs (VA)
Federal Bureau of Prisons (BOP)
Federal Communications Commission (FCC)
Food and Drug Administration (FDA)
Health Resources and Services Administration (HRSA)
Indian Health Service (IHS)
International Trade Administration (ITA)
National Aeronautics and Space Administration (NASA)
National Institutes of Health (NIH)
National Institute of Justice (NIJ)
National Institute of Standards and Technology (NIST)
National Science Foundation (NSF)
Office of the Assistant Secretary for Preparedness and Response (ASPR)
Office of the National Coordinator for Health Information Technology (ONC)
Substance Abuse and Mental Health Services Administration (SAMHSA)
Appendix C. ACA and Telehealth
The ACA created several incentives for telehealth advancement, mainly through Medicare and Medicaid pilots and programs.111 Although some of these ACA provisions do not explicitly mention telehealth, they provide support for using telehealth-related technologies. Some of the provisions have received funding. Although several provisions could include a role for telehealth, that information is not yet available. ACA Sections 3021, 3022, 3024, 6407, and 10328 explicitly allow telehealth technologies to be incorporated in and assessed through the grant making process. For example, grants under Sections 3021 and 3024 encourage the design and implementation of health care delivery models to support cost-reductions, quality and efficiency in the Medicare, Medicaid and SCHIP programs.
Appendix D. Telehealth and Telecommunications
Telehealth systems and networks rely on broadband, as well as specialized health equipment and advanced telecommunications. FCC officials state that
[b]roadband is essential to 21st Century health care, saving lives, improving the quality of care, and reducing costs by providing instant remote access over high-speed networks to medical specialists, health care records and training. Telemedicine applications provided over robust broadband networks can facilitate immediate diagnoses and care needed to prevent lasting damage to stroke victims, prevent premature births and deliver psychiatric treatment for patients in rural areas, to name a few examples.117
This appendix describes support for telehealth through broadband and telecommunications programs within the following four agencies/departments: (1) Federal Communications Commission; (2) Department of Commerce; (3) United States Department of Agriculture; and (4) Department of Health and Human Services.
Federal Communications Commission (FCC)
The FCC is the primary authority in the United States for communications law, regulation, and technological innovation.118 It regulates interstate and international communications activities connected with broadband programs, as well as television, cable and other communications media, and supports telehealth activities through various initiatives, including program funding and interagency coordination.
The Telecommunications Act of 1996 authorized the Rural Health Care Program.119 With funding capped at $400 million annually (from the Universal Service Fund), the Rural Health Care Program continues to seek improvements in health care quality for patients in rural communities by ensuring that eligible health providers have access to telecommunications and broadband services.120 The Rural Health Care Program is made up of three programs: the Healthcare Connect Fund, the Telecommunications Program, and the Rural Health Care Pilot Program.121
In 2010, the FCC recommended that HHS make arrangements with private insurers that contract with Medicare to receive tax credits for providing telehealth services to Medicare beneficiaries, but this recommendation has not yet been implemented.125 In 2014, the FCC created a new Connect2Health Task Force, seeking to support ongoing health telecommunications activities within the agency, and to provide an umbrella for all FCC health-oriented activities, including broadband adoption and health IT promotion.126 Since March 2014 the task force has led various activities at the local and national/federal level, such as roundtables in a "beyond the beltway" series of meetings,127 and has collaborated in a series of health technology related events with the Food and Drug Administration.128 The FCC and the ONC plan to increase broadband access in support of health care through 2020.129
United States Department of Commerce
The Department of Commerce supports telehealth primarily through grants to institutions for projects, and secondarily through collaborations with other federal agencies. Although its statutory mission is silent on an explicit telehealth role, the National Telecommunications and Information Administration (NTIA) oversees the Broadband Technology Opportunities Program (BTOP), which was established by ARRA.130 ARRA appropriated $4.7 billion for NTIA to establish BTOP to increase broadband access and adoption, provide broadband access, training and support to health care providers as well as to schools, libraries, and other organizations.
NTIA reports that telehealth project grants were awarded under competitive grants through BTOP, some amounting to $250 million or more for innovative programs that encourage sustainable broadband service.131 BTOP reports ongoing progress as well as impediments. For example, during 2014, BTOP reported 224 active awards. However, BTOP also reported that impediments such as lack of award acceptance, voluntary project termination and material noncompliance with grant terms and conditions are among the reasons for award cancellations or terminations.132
United States Department of Agriculture
The United States Department of Agriculture (USDA) administers telecommunications telehealth grants through two major programs: the Distance Learning and Telemedicine (DLT) Program133 and the Community Connect Program.134
The DLT Program funds institutions to support advanced telecommunications in health care and education in rural communities, and is designed specifically to assist rural communities that would otherwise be without access to learning and medical services over the Internet. It provides:
The Community Connect Program, whose primary objective is to expand broadband services to rural communities, provides financial assistance to state and local governments, federally-recognized tribes, non-profit organizations and for-profit corporations136 in rural areas that lack a minimum broadband speed connection. Funds may be used to
Department of Health and Human Services
The HHS's portfolio of telehealth activities spans several agencies. For example, the ONC138 coordinates some telehealth-related activities throughout HHS. HRSA139 and the Office of the Assistant Secretary for Preparedness and Response (ASPR)140 each develop policy for emergency preparedness, including telehealth capabilities that enable responders to communicate with authorities during a public emergency. Additional agencies such as the National Institutes of Health,141 AHRQ, CDC142 and the Food and Drug Administration (FDA)143 are applying telehealth functions within the scope of their agency missions. Of note, the Office for the Advancement of Telehealth (OAT) manages the following five types of telehealth grant programs that support telehealth coordination and telehealth networks:144
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ACA |
Patient Protection and Affordable Care Act |
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ACO |
Accountable Care Organization |
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AFHCAN |
Alaska Federal Health Care Access Network |
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AHRQ |
Agency for Healthcare Research and Quality |
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ANTHC |
Alaska Native Tribal Health Consortium |
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ARRA |
American Recovery and Reinvestment Act |
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ASPR |
Assistant Secretary for Preparedness and Response |
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BPCI |
Bundled Payments for Care Improvement |
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CHIP |
State Children's Health Insurance Program |
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CMS |
Centers for Medicare and Medicaid Services |
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DLT |
Distance Learning and Telemedicine |
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DOD |
Department of Defense |
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HER |
Electronic Health Record(s) |
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FCC |
Federal Communications Commission |
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Health IT |
Health Information Technology |
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HITECH Act |
Health Information Technology for Economic and Clinical Health Act |
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HPSA |
Health Professional Shortage Area(s) |
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HRSA |
Health Resources and Services Administration |
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IHS |
Indian Health Service |
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IOM |
Institute of Medicine |
|
LPGP |
Licensure Portability Grant Program |
|
MACRA |
Medicare Access and CHIP Reauthorization Act of 2015 |
|
MIPS |
Medicare Incentive Payment System |
|
NCSBN |
National Council of State Boards of Nursing |
|
NTIA |
National Telecommunications and Information Administration |
|
OAT |
Office for the Advancement of Telehealth |
|
ONC |
Office of the National Coordinator for Health Information Technology |
|
TATRC |
Telemedicine & Advanced Technology Research Center |
|
TNGP |
Telehealth Network Grants Program |
|
TRC |
Telehealth Resource Centers |
|
USDA |
United States Department of Agriculture |
|
VA |
Department of Veterans Affairs |
|
VHA |
Veterans Health Administration |
Author Contact Information
| 1. |
HRSA, Telehealth, http://www.hrsa.gov/healthit/telehealth/. |
| 2. |
"Store-and-Forward Telehealth involves the acquisition and storing of clinical information (e.g., data, image, sound, video) that is then forwarded to (or retrieved by) another site for clinical evaluation," http://www.telehealth.va.gov/sft/. Store-and-forward refers to the transmission of digital images, as in radiology or dermatology, for a diagnosis; http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Telehealth/whatistelehealth.html. |
| 3. |
Office of the National Coordinator for Health Information Technology (ONC), What is Telehealth? How Is Telehealth Different From Telemedicine?, https://www.healthit.gov/providers-professionals/faqs/what-telehealth-how-telehealth-different-telemedicine. This report uses the terms "telehealth" and "telemedicine" interchangeably, except where the distinction is appropriate, such as for legal, regulatory, and guidance purposes. For definitions of related terms, see Appendix A. |
| 4. |
For a list of those agencies, see Appendix B. |
| 5. |
VA, Department of Veterans Affairs Volume II Medical Programs and Information Technology Programs Congressional Submission FY 2017 Funding and FY 2018 Advance Appropriations, p. VHA-251, http://www.va.gov/budget/docs/summary/Fy2017-VolumeII-MedicalProgramsAndInformationTechnology.pdf. |
| 6. |
U.S. Congress, Senate Appropriations, Defense, Statement by Lieutenant General Patricia D. Horoho, Surgeon General of the United States Army, 113th Cong., 2nd sess., April 9, 2014, https://www.gpo.gov/fdsys/pkg/CHRG-113shrg49104596/pdf/CHRG-113shrg49104596.pdf. |
| 7. |
This amount represents $15.7 million for payments to physicians and other telehealth providers at the distant site, and $1.9 million for payments to facilities at the originating site. Source: CMS, Office of Legislation, February 19, 2016, email communication. |
| 8. |
Kylie Gumpert, "Telehealth services becoming popular with US consumers and insurers," December 23, 2015, Reuters, http://www.reuters.com/article/usa-healthcare-telemedicine-idUSL1N14B20B20151223. The article reports that examples of private insurers who are expanding telehealth utilization include UnitedHealth Group, Aetna, and Cigna. |
| 9. |
Foley & Lardner, LLP, Five Telemedicine Trends Transforming Health Care in 2016, November 16, 2015, https://www.foley.com/five-telemedicine-trends-transforming-health-care-in-2016/, and email communication with Nathaniel M. Lacktman, author, on February 10, 2016. Dale Van Demark, "States Begin 2016 with Expansion of Telehealth Services," The National Law Review, online, January 20, 2016, http://www.natlawreview.com/article/states-begin-2016-expansion-telehealth-services#sthash.A33ifm0f.dpuf. |
| 10. |
Five Telemedicine Trends Transforming Health Care in 2016. |
| 11. |
AHRQ, Telehealth: An Evidence Map for Decisionmaking, Draft Technical Brief, p. 39, http://www.effectivehealthcare.ahrq.gov/ehc/products/624/2160/telehealth-draft-report-151209.pdf. |
| 12. |
Telehealth: An Evidence Map for Decisionmaking, pp. 36-37. |
| 13. |
IOM, The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary, Washington, DC, 2012, p. 109, http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx. Hereinafter, The Role of Telehealth in an Evolving Health Care Environment. |
| 14. |
The National Quality Strategy (NQS) "establishes three aims, six priorities, and nine levers for quality improvement that are used by public and private organizations to chart a course for improved health and health care." The three aims are the focus of this report, and they are: (1) improvements in the health of the population by supporting proven interventions to address behavioral, social and, environmental determinants of health; (2) affordable health care for individuals, families, employers, and government; and (3) better access to quality care that is patient-centered, reliable, accessible, and safe. The NQS initiative is led by AHRQ. See http://www.ahrq.gov/workingforquality/reports/annual-reports/nqs2015annlrpt.htm. |
| 15. |
AHRQ, Working for Quality, About the National Quality Strategy (NQS), http://www.ahrq.gov/workingforquality/about.htm#aims. |
| 16. |
See Appendix D for a summary of telehealth-related telecommunications programs. For background on licensure portability, see, HRSA, Special Report to the Senate Appropriations Committee, Telehealth Licensure Report, Requested by S. Rept., 111-66, http://www.hrsa.gov/healthit/telehealth/licenserpt10.pdf. |
| 17. |
Rashid Bashshur, Gary Shannon, Elizabeth Krupinski, et al., "Policy: The Taxonomy of Telemedicine," Telemedicine and e-Health, vol. 17, no. 6 (July 2011); hereinafter, Bashshur, Shannon, Krupinski, et al. The authors state that the initial concept of telemedicine has expanded to include "a wide spectrum of applications and contexts. In turn the phenomenon has resulted in a parallel increase in concepts, labels, and definitions, some intersecting and others distinct" (p. 484). They argue that there is a lack of clarity and distinction between "telemedicine" and "telehealth" (p. 485). |
| 18. |
Telehealth: An Evidence Map for Decisionmaking, p. 8. |
| 19. |
According to the VHA, "asynchronous," or "store-and-forward" telehealth, involves capturing medical data (such as medical images, biosignals, and voice recordings) and then transmitting that data to a provider to do an offline assessment. Asynchronous communication does not require both parties to be present at the same time, http://www.telehealth.va.gov/. |
| 20. |
CMS, personal communication, April 2015. CMS, Medicare Managed Care Manual, "Remote Access Technologies (including Web/Phone based technologies and Nursing Hotline)" and "Telemonitoring Services," Rev. 120, 01-16-15, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf. |
| 21. |
Center for Connected Health Policy, The National Telehealth Policy Resource Center, State Telehealth Laws and Medicaid Program Policies, A Comprehensive Scan of the 50 States and District of Columbia, July 2015, cchpca.org/state-laws-and-reimbursement-policies. |
| 22. |
42 U.S.C. §1839(m), which applies to the Medicare Part B program for services provided via telehealth. |
| 23. |
42 C.F.R. §410.78. |
| 24. |
Appendix B contains a list of those agencies. |
| 25. |
Other agencies such as the Department of Justice/Bureau of Federal Prisons, and the Substance Abuse and Mental Health Services Administration either use, or provide grants for, telehealth in support for patient care. |
| 26. |
American Telemedicine Association, ATA Practice Guidelines for Live, On Demand Primary and Urgent Care, December 2014, http://www.americantelemed.org/docs/default-source/standards/primary-urgent-care-guidelines.pdf?sfvrsn=4. |
| 27. |
For example, the American College of Radiology publishes "guidelines that attempt to define principles of practice that should generally produce high-quality radiologic care," at http://imaging.stryker.com/images/ACR_Standards-Teleradiology.pdf. Further, AHRQ funds projects that seek to measure the impact of telehealth on the quality, safety, and efficiency of health care; see a list of projects at https://healthit.ahrq.gov/ahrq-funded-projects/emerging-lessons/telehealth. |
| 28. |
VA, Department of Veterans Affairs FY 2014-2020 Strategic Plan, pp. 7-8, http://www.va.gov/op3/docs/strategicplanning/va2014-2020strategicplan.pdf. |
| 29. |
VA, 2015 VA Agency Financial Report, Section I. Management Discussion and Analysis, Section I-7, http://www.va.gov/finance/afr/index.asp. |
| 30. |
A "unique" patient is "an individual treated by VA or whose treatment is paid for by VA." See CRS Report R44301, Veterans' Medical Care: FY2016 Appropriations, by [author name scrubbed]. |
| 31. |
VA, Real-Time Clinic Based Video Telehealth, http://www.telehealth.va.gov/real-time/index.asp. |
| 32. |
VA, Home Telehealth, http://www.telehealth.va.gov/ccht/index.asp. |
| 33. |
VA, Store-and-Forward Telehealth, http://www.telehealth.va.gov/sft/index.asp. |
| 34. |
VA, Audit of the Home Telehealth Program, March 2015, http://www.va.gov/oig/pubs/VAOIG-13-00716-101.pdf. |
| 35. |
VA, Veteran Health Care Utilization by Recent Veterans, http://www.publichealth.va.gov/epidemiology/reports/oefoifond/health-care-utilization/. The VA reports that as of 2014, the three most common diagnoses in the veteran population were musculoskeletal ailments (687,723, or 61.1%); symptoms, signs, and ill-defined conditions (i.e., conditions that do not have an immediately obvious cause or isolated laboratory test abnormalities) (641,973, or 57.0%); and mental disorders (640,537, or 56.9%). A veteran can have more than one diagnosis. |
| 36. |
VA, VA/DoD PTSD Coach App Wins Innovation Award for Telemedicine Advancement, press release, May 30, 2012, http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2320. |
| 37. |
VHA, VHA Vision Charting a New Direction: 2020, http://www.va.gov/healthpolicyplanning/vision2020.pdf. |
| 38. |
VA, VistA – eHEALTH, http://www.ehealth.va.gov/VistA.asp. VistA is the VA's core health IT system. It provides an integrated inpatient and outpatient electronic health record for VA patients, along with administrative tools. |
| 39. |
VA, My HealtheVet - The Gateway to Veteran Health and Wellness, https://www.myhealth.va.gov/ index.html. My HealtheVet offers veterans, active duty servicemembers, their dependents, and caregivers Internet access to VA health care information and services on a 24-hour, 365-day basis. The website also provides access to a free, online personal health record (PHR). |
| 40. |
VA, Blue Button Home, http://www.va.gov/BLUEBUTTON/. Blue Button facilitates access to patient medical records by the health care team. |
| 41. |
VA, Budget In Brief, FY2017, p. BiB-19. |
| 42. |
For example, in FY2012, VA home telehealth reduced hospital admissions by 38%, and resulted in savings of $1,999 per year per patient and patient satisfaction was recorded at 85% for home telehealth veterans. See, Alan Darkins, Telehealth Services in the Department of the VA, The Vision for Telehealth in the VA, Powerpoint slides, http://www.ncrar.research.va.gov/Education/Conf_2013/Documents/Darkins.pdf; and Andrew Broderick, The Veterans Health Administration: Taking Home Telehealth Services to Scale Nationally, Case Studies in Telehealth Adoption, The Commonwealth Fund, January 2013. |
| 43. |
Alan Darkins, Telehealth Services in the Department of the VA, The Vision for Telehealth in the VA, Powerpoint slides, http://www.ncrar.research.va.gov/Education/Conf_2013/Documents/Darkins.pdf; and Andrew Broderick, "The Veterans Health Administration: Taking Home Telehealth Services to Scale Nationally, Case Studies in Telehealth Adoption," The Commonwealth Fund, v. 4, no. 1657, January 2013. |
| 44. |
For more information on the MHS, including TRICARE, see CRS Report RL33537, Military Medical Care: Questions and Answers, by [author name scrubbed]. |
| 45. |
Military Health System and the Defense Health Agency, Clinical Information Management, http://www.health.mil/About-MHS/Defense-Health-Agency/Health-IT/Clinical-Information-Management. During FY2015, DOD was in the process of replacing these systems with what is known as the DOD Healthcare Management System Modernization (DHMSM), expected to be in operation by 2017. See, Military Health System and the Defense Health Agency, Defense Healthcare Management Systems Modernization Program Office Fact Sheet, http://www.health.mil/Reference-Center/Fact-Sheets/2015/05/19/Defense-Healthcare-Management-Systems-Modernization-Program-Office. |
| 46. |
DOD, Report to Congress: National Defense Authorization Act for Fiscal Year 2014, Section 702(b) Use of Telemedicine to Improve the Diagnosis and Treatment of Posttraumatic Stress Disorder, Traumatic Brain Injuries, and Mental Health Conditions, p. 10, http://tricare.mil/tma/congressionalinformation/downloads/ Mental%20Health%20Care%20Treatment%20Through%20Telemedicine.pdf. |
| 47. |
U.S. Congress, Senate Appropriations, Defense, Statement by Lieutenant General Patricia D. Horoho, Surgeon General of the United States Army, 113th Cong., 2nd sess., April 9, 2014, https://www.gpo.gov/fdsys/pkg/CHRG-113shrg49104596/pdf/CHRG-113shrg49104596.pdf. |
| 48. |
Statement by Lieutenant General Patricia D. Horoho, Surgeon General of the United States Army. |
| 49. |
Report to Congress: National Defense Authorization Act for Fiscal Year 2014, Section 702(b) Use of Telemedicine to Improve the Diagnosis and Treatment of Posttraumatic Stress Disorder, Traumatic Brain Injuries, and Mental Health Conditions. |
| 50. |
TATRC is an office within the headquarters of the United States Army Medical Research and Materiel Command, http://www.tatrc.org/. |
| 51. |
DCOE, T2 Health Programs, http://t2health.dcoe.mil/programs-telehealth.html. |
| 52. |
Joanna G. Katzman, George Comerci, and Jeannie F. Boyle, et al., "Innovative Telementoring for Pain Management: Project ECHO Pain," Journal of Continuing Education in the Health Professions, vol. 34, no. 1 (Winter 2014), pp. 68-75. |
| 53. |
Statement by Lieutenant General Patricia D. Horoho, Surgeon General of the United States Army. Also, in 2012, the ECHO Pain and Opioid Management TeleECHO Clinic (ECHO Pain) began a formal collaboration with the Department of Defense (Army), which set out to bridge the gap between primary and specialty care services in Army Medicine. This program aims to apply a holistic and multidisciplinary approach to delivering best practices for pain care to soldiers and their families," http://echo.unm.edu/initiatives/armed-services/. |
| 54. |
Committee on the Assessment of the Readjustment Needs of Military Personnel, Veterans, and Their Families; Board on the Health of Select Populations, Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families, IOM, National Academies Press, DC, March 12, 2013, Chapter 9. Access and Barriers to Care, http://www.nap.edu/catalog/13499/returning-home-from-iraq-and-afghanistan-assessment-of-readjustment-needs. |
| 55. |
HHS, IHS, FY2017 Justification, https://www.ihs.gov/budgetformulation/includes/themes/newihstheme/documents/FY2017CongressionalJustification.pdf. For more information on the IHS, see CRS Report R43330, The Indian Health Service (IHS): An Overview, by [author name scrubbed]. |
| 56. |
HHS, IHS, FY2016 Justification, http://www.ihs.gov/budgetformulation/includes/themes/newihstheme/documents/FY2016CongressionalJustification.pdf. |
| 57. |
In 2012, VA and the IHS announced a joint national agreement in which the VA agreed to reimburse the IHS for direct care provided to AI/AN veterans. Source: RAND Corporation, "A Product of the CMS Alliance to Modernize Healthcare Federally Funded Research and Development Center: Centers for Medicare & Medicaid Services (CMS)." Prepared for the VA, September 1, 2015 Prepared for CAMH under: Prime Contract No. HHS-M500-2012-00008I, p. 122. RAND researchers note that they "could not identify any literature on the full extent of the Indian Health Service's telehealth use…" (p. 133). |
| 58. |
AFHCP is a formal, voluntary, interagency relationship between the DOD, HHS (including IHS), VA, Alaska Native Tribal Health Consortium (ANTHC), and the Alaska Native Medical Center (ANMC), which share e-resources to improve patient care throughout the state of Alaska. See http://www.afhcp.org/about/. |
| 59. |
U.S. Congress, Senate Committee on Appropriations, Subcommittee on Military Construction and Veterans Affairs, and Related Agencies, VA's Collaboration with Indian Health Service: Improving Access to Care for Native American Veterans by Maximizing the Effective Use of Federal Funds and Services,112th Cong., 2nd sess., August 30, 2011, 112-703, pp. 13-19; http://www.gpo.gov/fdsys/pkg/CHRG-112shrg78226/html/CHRG-112shrg78226.htm. |
| 60. |
For information on AFHCAN, see http://www.afhcan.org/. |
| 61. |
Howard Hays, Mark Carroll, and Stewart Ferguson, et al., "The Success of Telehealth Care in the Indian Health Service," American Medical Association Journal of Ethics, vol. 16, no. 12 (December 2014), pp. 987-988. Hereinafter, Hays, Carroll, Ferguson, et al. For information on the ATHS, see http://anthctoday.org/index.html; and http://www.anmc.org/. |
| 62. |
AHRQ, "Telehealth Improves Access and Quality of Care for Alaska Natives," https://innovations.ahrq.gov/perspectives/telehealth-improves-access-and-quality-care-alaska-natives. |
| 63. |
For information on TTAC, see http://www.telehealthtechnology.org/about-us. |
| 64. |
Hays, Carroll, Ferguson, et al. |
| 65. |
For background information on Medicare, see CRS Report R40425, Medicare Primer, coordinated by [author name scrubbed] and [author name scrubbed]. |
| 66. |
For background information on Medicaid, see CRS Report R43357, Medicaid: An Overview, coordinated by [author name scrubbed]. |
| 67. |
For a history of telehealth under Medicare, see CMS, "Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014" 78 Federal Register 237, December 10, 2013, p. 74399. For a compendium of Medicaid telehealth policies, see Center for Connected Health Policy, State Telehealth Laws and Reimbursement Policies, http://cchpca.org/state-laws-and-reimbursement-policies. |
| 68. |
The Medicare program is authorized in Title XVIII of the Social Security Act. See Medicare Primer. |
| 69. |
For an overview of Medicare programs, see CRS Report R43122, Medicare Financial Status: In Brief, by [author name scrubbed]; and Medicare Primer. |
| 70. |
CMS makes payments to providers and or health plans for telehealth services under all parts, except Part A (hospital insurance). Under Medicare Part A, hospitals (and other inpatient facilities) might receive payments for telehealth activities. However, Medicare Part A does not define specific telehealth activities. Email communication from CMS, Office of Legislation, April 1, 2015. |
| 71. |
CMMI was established in the Patient Protection and Affordable Care Act (ACA) and supports the development and testing of innovative health care payment and service delivery models, http://innovation.cms.gov/. The ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). On March 30, 2010, the President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029). HCERA included several new health reform provisions and amended numerous provisions in the ACA. Several subsequently enacted bills made additional changes to selected ACA provisions. All references to the ACA in this report refer collectively to the law and to the changes made by HCERA and subsequent legislation. |
| 72. |
For telehealth-related sections in the ACA, see Appendix C. |
| 73. |
For more information on ACOs, see CMS, Accountable Care Organizations, General Information, http://innovation.cms.gov/initiatives/ACO/. ACOs are "groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients:" http://www.cms.gov/Medicare-Fee-for-Service-Payment/ACO/index.html. |
| 74. |
For information on the Bundled Payments for Care Improvement (BPCI) Initiative, see http://innovation.cms.gov/initiatives/bundled-payments/. |
| 75. |
CMS, Medicare Learning Network, Telehealth Services, https://www.cms.gov/Outreach-and-Education/Medicare-Learning Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf. |
| 76. |
The Social Security Act (SSA) Section 1834(m) (42 U.S.C. §1395m) authorizes the Secretary, by regulation, to establish Medicare payment for telehealth service under Part B. |
| 77. |
CMS, "Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for FY2015," 79 Federal Register 219, November 13, 2014. |
| 78. |
This is a definition of MSA established by the Office of Management and Budget, https://healthmeasures.aspe.hhs.gov/help/glossary |
| 79. |
Matlin Gilman and Jeff Stensland, "Telehealth and Medicare: Payment Policy, Current Use, and Prospects for Growth," Medicare & Medicaid Research Review, vol. 3, no. 4 (2013), page E8, http://www.cms.gov/mmrr/Downloads/MMRR2013_003_04_a04.pdf. |
| 80. |
This amount represents $15.7 million for payments to physicians and other telehealth providers at the distant site, and $1.9 million for payments to facilities at the originating site. Source: CMS, Office of Legislation, February 19, 2016, email communication. |
| 81. |
CMS, 2014 Medicare Trustees Report, Table II, B.1, p.11, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/index.html?redirect=/reportstrustfunds/. |
| 82. |
Gilman and Stensland, p. E8. |
| 83. |
CMS, "Announcement of Calendar Year (CY) 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter," April 6, 2015, at https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats/downloads/announcement2016.pdf. |
| 84. |
These may be a telephone system run by registered nurses administering protocol-driven, medically appropriate advice and scheduling office visits when necessary. Nursing hotlines are not explicitly defined in the Medicare Managed Care Manual. Alternatively, a functional definition appears in: Steven F. Magruder, J. Henry, and M. Snyder, "Linked Analysis for Definition of Nurse Advice Line Syndrome Groups, and Comparison to Encounters," MMWR Supplement, vol. 54 (August 26, 2005), pp. 93-97. Email communication from CMS, Office of Legislation, May 27, 2014. |
| 85. |
CMS, 2014 Medicare Trustees Report, Table II, B.1, p.11, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/index.html?redirect=/reportstrustfunds/. |
| 86. |
Email communication from CMS, Office of Legislation, April 1, 2015. Part D Medication Therapy Management (ACA Sec. 10328); and Durable Medical Equipment (DME) Face to Face (ACA Sec. 6407). See Medicare Primer. |
| 87. |
42 C.F.R. §423.153(d). For more information, See CRS Report R40611, Medicare Part D Prescription Drug Benefit, by [author name scrubbed] and [author name scrubbed]; and http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.html. |
| 88. |
CMS Memorandum dated April 7, 2015, "Contract Year CY 2016 Medication Therapy Management Program Guidance and Submission Instructions," http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.html. |
| 89. |
Email communication from CMS, Office of Legislation, May 27, 2014. |
| 90. |
AHRQ, Summary of AHRQ Health Information Technology Portfolio-Funded Projects as of 2008, Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Contract No. 290-04-0016, see study by Chrischilles, Elizabeth on Personal Health Records and Elder Medication Use Quality, https://healthit.ahrq.gov/sites/default/files/docs/page/2008_summary_full_report.pdf. |
| 91. |
CMS, 2014 Medicare Trustees Report, Table II, B.1, p.11, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/index.html?redirect=/reportstrustfunds/. |
| 92. |
Section 1115A of SSA established the CMMI, as added by the Sec. 3021 of the ACA. |
| 93. |
Lorenzo Moreno, Arnold Chen, and Leslie Foster, et al., Second Interim Report on the Informatics for: Diabetes Education and Telemedicine (IDEATel) Demonstration, Final Report on Phase I, Centers for Medicare and Medicaid Research, June 10, 2005, pp. 136-151, https://innovation.cms.gov/Files/Migrated-Medicare-Demonstration-x/IDEATel_SecondReport.pdf. |
| 94. |
Nancy McCall, Jerry Cromwell, and Kevin Smith, et al., Evaluation of Medicare Care Management for High Cost Beneficiaries CMHCB Demonstration: The Health Buddy Consortium Buddy® Consortium (HBC), CMS, RTI Project Number 0207964.025.000.001, April 2011, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/McCall_Eval_of_CMHCB_Demo_April_2011.pdf. |
| 95. |
In Round One and Round Two, CMMI has funded various projects with a telehealth component, http://innovation.cms.gov/Files/x/HCIATwoPrjProCombined.pdf. For example, in Round 1, telehealth is a primary function for the following grants: Upper Southwest Cardiac and Stroke Care ($1.7 million); Using Telemedicine in Patient Dialysis ($1.9 million); Comprehensive Stroke Care Model ($3.8 million); and Capital Clinical Integrated Network ($15 million). |
| 96. |
ACOs are "groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients." See, http://www.cms.gov/Medicare-Fee-for-Service-Payment/ACO/index.html. |
| 97. |
CMS, Bundled Payments for Care Improvement (BPCI) Initiative: General Information, http://innovation.cms.gov/initiatives/bundled-payments/. |
| 98. |
The other models are: (1) Primary Care Transformation; (2) Initiatives Focused on the Medicaid and CHIP Population; (3) Initiatives focused on the Medicare-Medicaid Enrollees; (4) Initiatives to Speed the Adoption of Best Practices; and (5) Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models, see http://innovation.cms.gov/initiatives/index.html#views=models. |
| 99. |
Round One was announced in November 2011, with three-year awards announced in 2012 and studies were expected to be completed in 2015. A 2014 CMS Report to Congress stated that it is too early to draw any conclusions about quality improvement or cost savings from the Innovation Awards Round One model tests. Subsequent Rounds will not produce results until after 2017. See CMS, CMMI, Report to Congress, December 2014, https://innovation.cms.gov/Files/reports/RTC-12-2014.pdf. |
| 100. |
P.L. 114-10 was enacted on April 16, 2015. |
| 101. |
For more on MACRA, see CRS Report R43962, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10), coordinated by [author name scrubbed]. |
| 102. |
MACRA, Sec. 101(b). |
| 103. |
CMS, "Medicare Program; Medicare Shared Savings Program: Accountable Care," 80 Federal Register 110, June 9, 2015, p. 32692. |
| 104. |
CMS, Next Generation ACO Model, http://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/. |
| 105. |
K. Blum and S.S. Gottlieb, "The Effect of A Randomized Trial of Home Telemonitoring On Medical Costs, 30-day readmission, mortality, and health-related quality of life in a Cohorts of Community-Dwelling Heart Failure Patients," Journal of Cardiac Failure, vol. 20, no. 7 (July 2014). R. Pekmezaris, I. Mitzner, and K.R. Pecinka, et al., "The Impact of Remote Patient Monitoring (Telehealth) Upon Medicare Beneficiaries With Heart Failure," Telemedicine Journal and e-Health, vol. 18, no. 2 (March 2012). |
| 106. |
D.C. Grabowksi and A.J. O'Malley, "Use of Telemedicine Can Reduce Hospitalizations of Nursing Home Residents Generate Savings for Medicare," Health Affairs, vol. 33, no. 2 (February 2014). M.A. Ward, "Pharmacist-provided Telephonic Medication Therapy Management in a MAPD Plan," American Journal of Managed Care, vol. 17, no. 10 (October 2011). |
| 107. |
CRS Report R42640, Medicaid Financing and Expenditures, by [author name scrubbed]. |
| 108. |
CMS, Telemedicine, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html. |
| 109. |
CMS, Telemedicine. |
| 110. |
For example, see the following studies on the effectiveness of telemedicine in Medicaid populations: W.C. Hitt, G. Low, and T.M. Bird, et al., "Telemedical Cervical Cancer Screening To Bridge Medicaid Service Care Gap For Rural Women," Telemedicine Journal and e-Health, vol. 19, no. 5 (May 2013); and S.E. Kim, A.J. Le Blanc, and C.Michalopoulos, et al., "Does Telephone Care Management Help Medicaid Beneficiaries With Depression?," American Journal of Managed Care, v. 17, no. 10 (October 2011). |
| 111. |
For more information, see CRS Report R41196, Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline, coordinated by [author name scrubbed]. |
| 112. |
The purpose of CMMI is to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP. Telehealth is explicitly included among the various demonstration models that the Secretary is authorized to support. CMS announced the first and second round of grants for Health Care Innovation Awards on May 8, 2012, and June 15, 2012, http://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/; and CMS, Fact Sheets, Health Care Innovation Awards Round Two To Deliver Better Care and Lower Costs, May 15, 2013, CMS Media Relations, 202-690-6145. |
| 113. |
CMS, Shared Savings Program, http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/. |
| 114. |
Similar to Sections 3021 and 3022, telehealth is explicitly identified as qualifying for use in an approved demonstration project. The Innovation Center is supporting two cohorts for the Independence at Home Demonstration. The first began in June 2012 and the second cohort began in September 2012. Individual practices, hospitals and consortia comprise the cohorts. See http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Medicare-Demonstrations-Items/CMS1240082.html. |
| 115. |
Information on the telehealth aspect of this project was unavailable for this report. |
| 116. |
Information on the telehealth aspect of this project was unavailable for this report. |
| 117. |
FCC, New Healthcare Connect Fund Expands Access to Broadband for Healthcare, December 12, 2012, https://www.fcc.gov/document/new-healthcare-connect-fund-expands-access-broadband-healthcare. |
| 118. |
CRS Report RL32589, The Federal Communications Commission: Current Structure and Its Role in the Changing Telecommunications Landscape, by [author name scrubbed]. |
| 119. |
P.L. 104-104 was enacted on February 8, 1996. FCC, Universal Service, https://www.fcc.gov/encyclopedia/universal-service. |
| 120. |
FCC, Rural Health Care Program, Supporting Broadband Connectivity to Health Care Providers, https://www.fcc.gov/encyclopedia/rural-health-care. |
| 121. |
Rural Health Care Program, Supporting Broadband Connectivity to Health Care Providers. |
| 122. |
FCC, FCC Releases Healthcare Connect Order, https://www.fcc.gov/document/fcc-releases-healthcare-connect-order. |
| 123. |
FCC, Rural Health Care Program, Telecommunications Program, https://www.fcc.gov/encyclopedia/rural-health-care#TP. |
| 124. |
FCC, Rural Health Care Program, Rural Health Information Fact Sheet, https://www.fcc.gov/encyclopedia/rural-health-care-pilot-program#faqs. |
| 125. |
National Broadband Plan, p. 205. |
| 126. |
FCC, Connect2HealthFCC Task Force To Hold First Broadband Health, Press Release, November 17, 2014, https://www.fcc.gov/document/fcc-connect2health-task-force-holds-first-broadband-health-roundtable. |
| 127. |
FCC, Just Around the Broadband Bend, http://www.fcc.gov/blog;just-around-broadband-bend, February 24, 2015. |
| 128. |
FCC and FDA Joint Workshop: the role of Wireless Test Beds, https://www.fcc.gov/events/fcc-and-fda-joint-workshop-promoting-medical-technology-innovation-role-wireless-test-beds, March 31, 2015. |
| 129. |
ONC, Federal Health IT Strategic Plan, 2015-2020, https://www.healthit.gov/sites/default/files/9-5-federalhealthitstratplanfinal_0.pdf. |
| 130. |
In 2010, Congress passed P.L. 111-226, rescinding $302 million from BTOP, thereby decreasing funding levels to approximately $4.4 billion. See http://www.ntia.doc.gov/files/ntia/publications/ntia_btop_25th_qtrly_report.pdf. |
| 131. |
NTIA, BroadbandUSA, Georgia Partnership for TeleHealth, Inc., http://www2.ntia.doc.gov/files/grantees/georgia_partnership_for_telehealth.pdf, September 2010. |
| 132. |
http://www.ntia.doc.gov/report/2015/twenty-fifth-quarterly-status-report-congress-regarding-btop. |
| 133. |
The DLT Program is authorized in the Federal Agriculture Improvement and Reform Act of 1996, Title VII, P.L. 104-127, 7 U.S.C. 950. For funding, see USDA, FY2015 Budget Summary and Annual Performance Plan, p. 42, http://www.obpa.usda.gov/budsum/FY15budsum.pdf; and http://www.usda.gov/wps/portal/usda/usdahome?contentid=2015/05/0146.xml&contentidonly=true. |
| 134. |
USDA, Community Connect Grants, http://www.rd.usda.gov/programs-services/community-connect-grants. |
| 135. |
For information on USDA grants, see, USDA, RUS, DLT Awards, FY2013, http://www.rurdev.usda.gov/SupportDocuments/UTP-Community-Connect-Factsheet.pdf. |
| 136. |
The projects funded by these grants help rural residents tap into the enormous potential of the Internet for health care as well as jobs, education, public safety and community development, at http://www.rd.usda.gov/programs-services/community-connect-grants. |
| 137. |
USDA, RUS, "Community Connect Broadband Grant Program," 78 Federal Register 25792, May 3, 2013. |
| 138. |
About ONC, http://www.healthit.gov/newsroom/about-onc. |
| 139. |
HHS, HRSA, Telehealth, http://www.hrsa.gov/telehealth/. |
| 140. |
ASPR is the leading agency for all health and medical services support functions during a health emergency or public health event; see http://www.phe.gov/about/aspr/pages/default.aspx. See the report Pandemic and All-Hazards Preparedness Act, Telehealth Report to Congress, authorized in P.L. 109-417, http://www.phe.gov/Preparedness/legal/pahpa/Documents/telehealthrtc-091207.pdf. |
| 141. |
NIH, Research Portfolio Online Reporting Tools (RePORT), http://www.nibib.nih.gov/research/scientific-program-areas/telehealth. This program supports technology development that incorporates telemetry and remote access in the acquisition, analysis, and monitoring of biomedical data. The National Institute of Biomedical Imaging and Bioengineering supports the development of software and hardware for telehealth studies that have broad applications, as well as early stage development of telehealth technologies that may have specific focus areas; see http://www.nibib.nih.gov/research/scientific-program-areas/telehealth. |
| 142. |
CDC aims to protect the United States from safety and security threats, both international and domestic, fights disease and supports communities and citizens to do the same, see http://www.cdc.gov/about/organization/mission.htm. |
| 143. |
The FDA oversees the safety and effectiveness of medical devices, including mobile medical apps. In September 2013, the FDA issued the Mobile Medical Applications Guidance for Industry and Food and Drug Administration Staff. The guidance explains the agency's oversight of mobile medical apps as devices and the agency's focus only on high-risk apps (or those that present a greater risk to patients if they do not work as intended). For more on medical mobile applications, see http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ConnectedHealth/MobileMedicalApplications/ucm255978.htm. |
| 144. |
For additional information on each of these programs, see HRSA Justification of Estimates for Appropriations Committees, FY2015, p. 392, http://www.hrsa.gov/about/budget/budgetjustification2015.pdf. For information on tele-emergency grants, see HHS, HRSA, $22.1 Million to Improve Access to Health Care in rural Areas, September 26, 2014, http://www.hrsa.gov/about/news/pressreleases/140926ruralhealth.html. |
| 145. |
PHSA, Sec. 330I(d)(1); 42 U.S.C. §254c-14(d)(1). See HRSA, OAT, The Telehealth Network Grant Program (TNGP), at http://www.hrsa.gov/ruralhealth/about/telehealth/telehealthnetworkgp.pdf. |
| 146. |
PHSA, Sec. 330I(d)(2); 42 U.S.C. §254c-14(d)(2). See http://www.telehealthresourcecenter.org/. |
| 147. |
PHSA Sec. 330L; 42 U.S.C. §254c-18. See OAT Grantee Profiles, 2012-2013, http://www.hrsa.gov/ruralhealth/about/telehealth/directory1213.pdf. |
| 148. |
SSA, Sec. 711(b); 42 U.S.C. §912. See, grants.gov, http://www.grants.gov/web/grants/view-opportunity.html?oppId=255433; and http://www.hrsa.gov/ruralhealth/about/telehealth/. |
| 149. |
SSA Sec. 711(b); 42 U.S.C. §912. See, https://grants.hrsa.gov/2010/Web2External/Interface/FundingCycle/ExternalView.aspx?fCycleID=f828507e-99e0-4ace-8ed0-e0b651ab04d5. |