Remember “the Jetsons,” the 1960s futuristic cartoon, in which robotic appliances controlled the Jetsons’ home, their cars could fly, their pet dog was a robot, and life was made all better by technology?

These days, if you’re one of the 7,500 Mercy Hospital patients in five different states in the Midwest and the South served with telemedicine, your health care might make you feel a bit like you were one of the Jetsons.

Right now, patients can be sitting in a bed recovering from a major illness at their local hospital. When it’s time for the nurse’s check-in, instead of seeing an actual person, they see a camera whirl around and a monitor lights up to show a smiling face with a headset on. The medical professionals, who are hundreds of miles away in a command center in St Louis, Mo., can do heart monitoring, blood pressure, respiratory rates, temperatures – all on a 24/7 basis. This high-tech monitoring, which the St. Louis-area hospital calls “Mercy Virtual,” is especially effective for patients in rural areas.

Another hospital doing virtual care with cameras from remote locations is the Carolinas Health Care System, which is using telemedicine to monitor intensive care units in 10 of its hospitals. From a command center near Charlotte, N.C., a 24-7 rotating crew of nurses and doctors who specialize in critical care, monitor every room through a computer screen that allows the patient to see and converse with a nurse at any moment.

If this can work successfully in the intensity of an ICU, imagine the benefits that can be found with frail elderly people who can’t easily get to the hospital?

The Major Barrier? Medicare Acceptance Despite Evidence of Success

For now, the biggest barrier to adoption of this technology by seniors is Medicare itself. Medicare refuses to pay for it, or allow insurers to pay for it, except in very limited circumstances.

You can’t help but see the irony for many homebound seniors who have trouble getting to and from hospitals and doctor’s offices. They could greatly benefit from being able to use a cell phone, computer or some kind of video screen to see their doctor for routine care at home, but can’t take advantage of the technology because Medicare won’t pay insurers to use it.

But while seniors aren’t taking advantage of telemedicine, the rest of the country is. This new technology is becoming one of the fastest-growing sectors in the health care industry. Aetna and United Healthcare, two of the larger insurers, cover telemedicine services for members under age 65 regardless of whether folks live in the city or in rural areas. Medicare only covers people under limited circumstances, primarily in rural areas underserved by doctors.

Medicare officials seem to have a mind-set that the health of the elderly is far more complicated than younger folks. But experienced doctors challenge that assumption. Online doctors know when they can handle health issues – and when, instead, they should advise people to see a doctor in person or head to an emergency room or urgent care clinic. “Our intent is not to replace their primary care physician, but to augment their care,” Dr. Mia Finkelston, a Maryland-based family physician told Kaiser Health News recently.

An article in the July issue of the New England Journal of Medicine points out the strong potential of telemedicine. Already, those using virtual visits with a physician around the clock are finding they can charge an average cost of less than $50 per visit. Some have found they can charge as little as $15 for an online visit. By contrast, it takes, on average, 20 days to secure a 20-minute appointment with a physician that, with travel and waiting, can consume two hours of an individual’s time, the doctors found.

In the future, doctors predict frequent virtual visits will add the next wave of medicine and technology – remote wearable devices. That, of course, will be supplemented by actual in-person visits with doctors, nurses, therapists and social workers. They expect this could provide a new model to treat common conditions, such as congestive heart failure and diabetes.

But Medicare remains skeptical that telemedicine saves money and the federal government also questions how effective it is. Medicare currently limits reimbursement for telemedicine to only a specific few situations in which live video encounters between doctors and patients at a clinic or medical facility in a rural area. While 29 states have passed telemedicine laws allowing reimbursement by commercial insurers, there is not a generally accepted reimbursement standard for private payers.

Despite Medicare’s limited usage, many Medicare patients are using telemedicine. Visits jumped from 7,015 in 2004 to 107,955 in 2013, according to a recent study in the Journal of the American Medical Association. But that study found that the majority of those beneficiaries were under 65 and got Medicare coverage due to disability.

Pressing for Progress

There’s plenty of pressure on Medicare to change its reimbursement rules. In May, 22 health systems and several major health organizations wrote a letter to Keith Hall, head of the Congressional Budget Office, urging his help to push the use of commercial data to help evaluation the effectiveness of telehealth. They argued that Medicare doesn’t understand how useful the technology is because its rules are so out of date that little data is available.

The reason it isn’t evolving is because it’s trapped in the law that isn’t evolving with modern medicine,” Joel White, executive director of the Health IT Now Coalition told Kaiser
Health News recently. His group is urging Medicare to loosen its strict limits on telemedicine.

Despite Medicare’s inactivity, Modern Healthcare reported in 2014 that 29 states and the District of Columbia have enacted private telehealth coverage laws and that number is expected to increase to 32 by 2017.

Medicare’s only move forward lately has been proposing a minor expansion of payment rules that would include telehealth as well as behavioral health visits. Last year, Medicare paid out $17.6 million in telehealth reimbursements out of a total $546 billion in Medicare expenditure, or .003 percent.

Medicare’s rules are so stringent, that it won’t even permit phone therapy for patients with anxiety or depression, unless the beneficiary drives to a local medical facility. But local is a relative term. Many seniors in rural areas have to drive more than 100 miles to reach medical facilities, so it’s hardly convenient.

Some states have figured out a work-around Medicare, at least for some patients. In the state of Missouri, some Medicare Advantage plans offering Anthem Blue Cross allows patients to log on to Live Health Online https://startlivehealthonline.com/landing.htm, a telemedicine platform that visually connects customers to doctors around the country from their computer, tablet or cell phone.

Anthem, which has been aggressively pushing telemedicine, provides that option to about 350,000 Medicare Advantage members in 12 states, mostly through accountable care organizations (ACOs). Medicare Advantage can take advantage of telemedicine without the tight restrictions that traditional Medicare has because they are paid a fixed amount by the federal government to care for seniors, not specific dollar outlays for telemedicine.

Perhaps the strongest argument in favor of telemedicine is the expected drastic shortage of primary care physicians in the United States. With millions of baby boomers on the verge of retirement, the Association of American Medical Colleges estimates that by 2025 there will be a shortfall of between 12,500 and 31,100 primary care physicians in the United States, with rural areas the hardest hit.

Congress and the federal government have kept up restrictions against telemedicine, analysts suggest, out of concern that the services might increase Medicare expenses. Lawmakers warn that giving seniors access to doctors online will encourage them to use more services, not replace costly visits to emergency rooms and urgent care centers.

Advocates for telemedicine like the American Medical Association, the American Academy of Family Physicians and the American Hospital Association argue that beneficiaries getting online care would ultimately reduce doctor visits and emergency care and are urging Congress to expand use of telemedicine in Medicare. The AMA recently adopted a set of guidelines for coverage and reimbursement of telemedicine services designed to encourage Medicare to treat them the same as traditional consultations. But so far, Medicare has not moved in that direction.

It’s easy to understand why insurers remain skeptical of telemedicine. They argue that if it really saved money, everyone would be falling over themselves to pay for it. From the insurer’s eyes, online visits can lead to more tests and more follow-up visits, not less of these.

But the biggest reservation doctors and insurers have are the limits it can place on a doctor to get the full health story of a patient. This is about patient safety, doctors say. How can a physician make an accurate diagnosis when they have no objective diagnostic data? All they have is what the patient has told them, and often that’s not enough information, some physicians argue.

Mari Robinson, executive director of the Texas Medical Board was asked recently why Texas imposed strict rules preventing many types of telemedicine. “No one would think if they showed up at their doctor’s office they would go back to a room, have the doctor stand on one side of the door, they would stand on the other, tell the doctor their symptoms and the doctor would slip a prescription under the door. No one would think that was good care,” said Robinson. “That is exactly the same as doing it over a telephone,” she told Kaiser Health News recently.   

AARP, the seniors lobby, wants Congress to allow all Medicare beneficiaries to have coverage for telemedicine services. But AARP has stressed that telemedicine should be used in conjunction with seniors seeing their regular doctors.

Lawmakers are pushing to force Medicare’s hand in favor of telemedicine. Many states have implemented roadblocks for simple telephone therapy with laws requiring that anyone giving medical care must be licensed in the state where the patient resides. Reps. Frank Pallone, D-N.J. and Devin Nunes, R-Calif., offered a bill last year that would allow providers licensed in one state to provide care in another state electronically. But so far, that hasn’t gotten anywhere.

Earlier this year, some lawmakers tried to add telemedicine legislation to the law that revamped Medicare doctor payment rules and to the House bill that sought to streamline drug approvals. But those efforts were unsuccessful. New efforts are expected in the next session of Congress.

A number of states have allowed their Medicaid programs to reimburse for telemedicine and changes enacted under the Affordable Care Act. For example, the rise of bundled payments may provide additional opportunities for using telemedicine. So if you have elective surgery, for example, a doctor might be able to do some follow-up care via telemedicine without you needing office visits.

The other big obstacle in the telemedicine mix is the digital divide – where older, low income seniors who have chronic conditions and who might need it the most, are the least likely to have the internet access. All kinds of government efforts are being made to cover that problem, but telemedicine has so far not been a part of those discussions.

[Also contributing to this story was Kaiser Health News, the St. Louis Post Dispatch, New England Journal of Medicine, JAMA, NPR, WFAE, KCUR and Modern Healthcare.]

Alan Schlein runs DeadlineOnline.com, an internet training and consulting firm. He is the author of the bestselling “Find It Online” books.

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