Print´╗┐ BCTV: Telehealth -- Sen. Tom Daschle, telemedicine accessibility, regulatory challenges


Transcript of BioCentury This Week TV Episode 191



Former Sen. Tom Daschle, senior policy advisor at law firm DLA Piper


Dr. Ray Dorsey, professor of neurology and co-director of the Center for Human Experimental Therapeutics at the University of Rochester Medical Center


John Jesser, VP and general manager of LiveHealth Online at WellPoint




Kaiser Permanente

Veterans Administration


Health Insurance Portability and Accountability Act

Federation of State Medical Boards

LiveHealth Online

Alliance for Connected Care



Erin McCALLISTER, Senior Editor




ERIN McCALLISTER: Telehealth. Is this next generation of house calls the future of medicine? We'll hear from a doctor, a payer, and former Senator Tom Daschle who all want it to go viral. I'm Erin McCallister. Welcome to BioCentury This Week.




NARRATOR: Connecting patients, scientists, innovators, and policymakers to the future of medicine. BioCentury This Week.


ERIN McCALLISTER: Telehealth takes advantage of the advances in high-speed internet to connect doctors with patients hundreds of miles away. The practice would replace many office visits with in-home online checkups to monitor patients and diagnose some of the most complex diseases. Telehealth could reduce costly ER and specialist visits and improve patient compliance with their treatment regimens.


Dr. Ray Dorsey of the University of Rochester has shown it's possible. He has been using telemedicine to diagnose and treat Parkinson's patients for more than six years, but reimbursement and a patchwork of state laws stand in the way of taking telehealth mainstream. In most states, licensing requirements limit the reach of telehealth, which could leave some patients without specialist care.


A group of healthcare leaders have formed the Coalition for Connecting Care to change that, led by former Senator Tom Daschle and health plan giant WellPoint, the group is trying to make telemedicine accessible for all Americans, including those on Medicare. Today, we'll talk about the promise of telehealth and what is being done to expand access on a national scale. We'll hear from Senator Daschle as well as John Jesser, who leads WellPoint's telehealth initiative.


But first, I'm pleased to be joined by Dr. Ray Dorsey, professor of neurology and co-director of the Center for Human Experimental Therapeutics at the University of Rochester Medical Center. Dr. Dorsey, thanks for joining us today.


DR. RAY DORSEY: Thank you for having me.


ERIN McCALLISTER: You have been using telehealth, and you're really regarded as one of the pioneers in telemedicine. Can you tell us how you've been using it and what your experience has been?


DR. RAY DORSEY: Well, the real pioneers have been using it for 20 or 25 years, but we've been using it for the last six years to connect to individuals with Parkinson's disease, initially those in nursing homes and, more recently, directly to patients in their own homes.


ERIN McCALLISTER: Mm-hmm. And what sort of led you down that path, in terms of what got you to using telehealth?


DR. RAY DORSEY: Well, it turns out that over 40% of Medicare beneficiaries with Parkinson's disease do not see a neurologist. And those who do not see a neurologist are 20% more likely to fall and fracture a hip, 20% more likely to be placed in a skilled nursing facility, and 20% more likely to die. So we've been trying to use simple, inexpensive technology to connect directly to patients -- initially, in a nursing home that contacted us and said that many of their residents have Parkinson's disease but aren't able to access the right care.


ERIN McCALLISTER: And how far away from you were these patients?


DR. RAY DORSEY: The initial patients that we saw were in a town called New Hartford, New York, population 20,000 --




DR. RAY DORSEY: -- outside of Utica, New York, outside of Syracuse, about 200 miles away or 2 a 1/2 hours from us, in Rochester.


ERIN McCALLISTER: Oh, OK. And so you did that a few years ago. And you saw -- what did you see with doing that?


DR. RAY DORSEY: We showed that providing care to these individuals was, one, feasible, two, improved their quality of life, and, three, even improved their Parkinson's disease symptoms.


ERIN McCALLISTER: I mean, so when someone thinks about a disease, like Parkinson's disease, you know, you think fairly technical -- you know, that's a disease. It's a CNS disease. It involves the brain. I would -- you know, an initial thought would be -- you can't do that from the comfort of your own home. But what is it about Parkinson's disease that allows something like this to actually work?


NARRATOR: The nice thing about Parkinson's disease -- and many disorders -- is that it's primarily visually assessed. So we can do 90% of the exam that we would normally do in-person we can do it remotely. And we and others have demonstrated that the exam, when conducted remotely, closely correlates to the exam when done in-person.


ERIN MCCALLISTER: Mm-hmm. And one of the other things, I would think, with telehealth is -- you're capturing these people you know, in their everyday lives. What sort of benefit might that have versus them coming to the doctor's office? And, you know, there's certain things I'll do before my doctor's appointment that I might not do before sitting down in front of the computer.


DR. RAY DORSEY: So when we ask patients what were the benefits that they saw, they came out with three Cs. One is care. The second is convenience, and the third is comfort. So, one, they were able to access care that they otherwise wouldn't be able to do. Two, they were able to do it in a convenient manner without having to drive, pay for parking, take time off from work. And three, they said that they were actually more comfortable receiving care in their home than they would be in-person.




DR. RAY DORSEY: On our end, we're able to get a much better sense of the individual, their social and economic factors that are affecting their lives and their conditions. We see their pets. We'd see their spouses. We see there's people cooking soup in the kitchen.


ERIN McCALLISTER: Mm-hmm. And so I would have to think, though, are there any disease areas maybe where telehealth isn't a good option?


DR. RAY DORSEY: Telehealth probably works best when individuals are already diagnosed with a condition. And then, you already know they have Parkinson's disease. You already know they have epilepsy. You already know they have Alzheimer's disease. This is a tremendous way to provide ongoing care to individuals, once they've been diagnosed with a condition. There's certainly conditions that are very difficult to assess remotely. You know, if someone has appendicitis --




DR. RAY DORSEY: -- it's not the way to do -- telemedicine is probably not the best application.


ERIN McCALLISTER: Sure. And just switching gears here a little bit -- in clinical trials, we hear a lot about populations being underrepresented because maybe they don't live near a major medical facility. Can telehealth be used to change that and make clinical trials more relevant in terms of the patient populations?


DR. RAY DORSEY: We're just scratching the surface of what is possible. So you can imagine, for children with a rare disorder, there may not be a pediatrician in their state or in their region who can care for them or participate in a clinical trial.


And currently, the standard of care is that people fly all over to major urban centers to participate in clinical trials and have to do that repeatedly. If someone's in a wheelchair or someone's neurologically devastated or has any other barriers, that's very expensive. We think that these simple, inexpensive technologies that people use to communicate with their grandchildren can be used to help enable children to participate in clinical trials are those rare disorders to be connected to specialists wherever they are.


ERIN McCALLISTER: Thanks, Dr. Dorsey. Next, we'll talk with John Jesser, head of telehealth at WellPoint. But first, here's a look at how telemedicine compares with traditional office visits in treating Parkinson's disease.




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ERIN McCALLISTER: I'm pleased to be joined by John Jesser, vice president and general manager of LiveHealth Online at WellPoint.


John, thanks for joining us. One of the things WellPoint is doing is LiveHealth -- is this program called LiveHealth Online. Can you explain that a little bit and how that works?


JOHN JESSER: Yes, Erin. Probably the best way to explain it is to give you an example. It's 10 o'clock on a Friday night. You don't feel well. Your doctor's office is closed for the weekend. And today, you really have two or three options.


You might have an emergency room nearby -- expensive, a long wait. Again, assuming this is not life-threatening emergency. Maybe there's an urgent care nearby. That tends to add up cost-wise as well, and it's inconvenient. There might be a retail clinic. You know, maybe one of the drug stores that has one of these nurse practitioner retail clinics. Those are your choices.


But with LiveHealth Online, now you have a new choice. You can open up your laptop -- if you have a webcam -- or pull out your Apple or Android mobile device or your tablet, and, within less than 10 minutes, be face-to-face with a board-certified credentialed doctor who's licensed in your state in a HIPAA-compliant, secure conversation.




JOHN JESSER: So you go to the doctor. They can see you. And in many states, the doctor can prescribe something, if it's necessary, based on their judgment. So it's really a new tier of care.




JOHN JESSER: And where we're introducing it and rolling it out to consumers across the country.


ERIN McCALLISTER: OK. And so a couple things that you mentioned there, and I want to get back to that prescription drug piece in a second. But in terms of why WellPoint decided to do this. You know, we heard from Dr. Dorsey. He's been doing telehealth for about six years. You know, why did WellPoint decide to, you know, get into the telehealth game?


JOHN JESSER: That's a great question. You know, for years -- I've been working with doctors and hospitals for about 20 years. And they often say, I do a lot of work on the phone. Why don't health plans pay me for it? And quite -- it's a great question. And, quite honestly, the answer is no one really knows what happened on the phone.




JOHN JESSER: Was it a 5-minute conversation? Was it 20 minutes? Was there documentation? So when we started to look at the telehealth technology out there -- and so much has changed. Historically, telemedicine was a room in a hospital with video equipment and a specialist and then a room at a community health center or a doctor's office in a rural area where a patient and a doctor would sit. And it was very much controlled and scheduled.


Today -- with high-speed internet, with the video compression, and the technology that's available -- telehealth means that healthcare can be available on demand.




JOHN JESSER: So that suddenly changes everything. And so that's just one of the big important changes that have led to this.


ERIN McCALLISTER: OK. And one of the things that you talked about just a second ago was -- in your earlier example, you said that, in some states, they can prescribe medicine.




ERIN McCALLISTER: So can you talk a little bit more about that? Because not in every state can they prescribe medicine in?




ERIN McCALLISTER: So what the challenge is there.


JOHN JESSER: It presents quite a challenge, especially because -- what we saw in your first question -- with the structure around this, the HIPAA compliance, the security, the fact that there's a medical record, we know what's going on. So as a health plan we decided, we should cover this. This is legitimate healthcare. It should be a covered benefit.


So as we roll that out across the country to employers, their challenge is every state or many states vary. For example, a new patient can meet a physician in California online electronically and establish a relationship. And if that physician, using their medical judgment feels they need to write a prescription, they can do that. Yet in Texas--




JOHN JESSER: -- a physician and patient can't even set up an electronic visit and establish a relationship. So for an employer that has employees all around the country, they have to figure out, well, so who can use this and who can't?


ERIN McCALLISTER: Right. And then, I just -- real quick, we don't have a lot of time left. But it seems like you have to have certain technology in your home to be able to use tools like LiveHealth Online. So doesn't that still kind of create barriers for some people that maybe don't have high-speed internet? I know it's hard to believe, but there are still some people with dial-up connections, so.


JOHN JESSER: Correct. You know, the good news is every month, every year that goes by, this will be less and less an issue. All the communications literature shows that 90% of communication is nonverbal.




JOHN JESSER: So it's not just what's said. We've worked with doctors and medical boards around the country and the Federation of State Medical Boards in Washington. And really, the doctor's best able to get the richest information from a live video conversation.


ERIN McCALLISTER: Is this a pilot program, or this is already -- is this widely available in terms of its use?


JOHN JESSER: It's actually available right now to three and a half million people that have health plans through one of WellPoint's companies, but also to anyone. So if you or anyone went to or downloaded the free mobile app -- 24 hours a day right now, 7 days a week, 365 days a year, in 44 states -- it's there.


ERIN McCALLISTER: So they go through this, like, you say, like, at 11 o'clock at night and, the next morning, they need a follow-up checkup, is this something where they can then go to their regular doctor or what's --


JOHN JESSER: They can.




JOHN JESSER: Yes. So these are board-certified, trained doctors. They're credentialed. After the visit, the patients ask the question, "Would you like to forward a record of this visit to your doctor?" They can either download it, keep it, print it, or they can -- with one click -- send it through a secure email to their doctor or they can click and have it faxed. So the continuity of care is built into it.


ERIN McCALLISTER: Mm-hmm. And in terms of -- one of the things that sort of makes sense to me is I think about telehealth and, you know, treatment compliance and treatment -- you know, drug regimens and things like that and the issues associated with people not being compliant. It seems like telehealth might be able to play a role in there, say, if you have side effects for --


JOHN JESSER: And when you listen to all the pharmaceutical commercials, they always end up with, "Ask your doctor about it" --




JOHN JESSER: All right. Well, you just may want to ask a doctor. And you might not want to make an appointment and leave work. So, you know, let me go online and ask a doctor. The retail price of the visit is $49. Let me spend some time and ask a doctor these questions.


The other thing is the doctors that are there see people that need a refill or they have questions about complications. And it might be at night or they're at work during the day and their doctor's office isn't available.




JOHN JESSER: So it really does help augment -- Senator Daschle uses the phrase -- "death to distance."




JOHN JESSER: It's no longer driving and parking and all these things that are barriers to healthcare.


ERIN McCALLISTER: But on a routine day-to-day, you know, a working mom who has, you know, 50 minutes at lunchtime, can she use telehealth because she's got a kid who's got a cough or something?


JOHN JESSER: Absolutely. Absolutely. That's really the story we're hearing over and over.


It's the working mom. It's 9 o'clock at night. Three kids, one of them's sick. And she's trying to decide -- do I call in tomorrow morning to the doctor, try to get an appointment, then call the child out of school, and then get out of work to go make all this happen? And what happens is they're calling us and saying, "I just went online at 9 o'clock. We saw the doctor, took care of the issue. The doctor gave us a slip that said the child's not contagious --




JOHN JESSER: -- put them on a medication, if it was needed, and I'm done by 9:15. So it's very much a convenient thing for moms.


ERIN McCALLISTER: Great. Well, next, we'll talk with former Senator Tom Daschle. But first, here's a look at the states that allow patients to access prescription drugs after a telehealth visit.







NARRATOR: Now, back to BioCentury This Week.


ERIN MCCALLISTER: Today, we're talking about the future of telehealth. I'd like to welcome Senator Tom Daschle, now senior policy adviser at the law firm DLA Piper. Senator Daschle, thank you for joining us today.


TOM DASCHLE: My pleasure, good to be with you.


ERIN MCCALLISTER: Great. And so as we just heard, we've heard from Doctor Ray Dorsey and John Jesser. And one of the things I want to get your take on is why are we now talking about telehealth? It's been in practice for a while now, but why now this groundswell of support from things like the Coalition for Connected Care?


TOM DASCHLE: I would say, in large measure, because policy is just now beginning to get caught up with technology. Policy has been way behind the curve. Technology has exceeded our capacity to deal with many new opportunities that exist as a result of the dramatic transformation we've seen through telehealth and teletechnology. So as a result, lawmakers and policy makers generally are trying to say what kind of a framework can we create through policy to accommodate this dramatic and exciting new change in telehealth?


ERIN MCCALLISTER: And your Coalition has earmarked some very specific issues that stand in the way of taking telehealth viral, so to speak. What are some of those challenges?


TOM DASCHLE: Well, there are two categories really. There are state categories of challenge that we have to face. Every state has its own rules and regulations with regard to when telemedicine and telehealth can be used effectively. A lot of those are way behind the times when it comes to a full appreciation of the applicability of telehealth to good medicine today.


Then at the federal level, we have much the same issue. We go back about 15 years since the last time we really saw a major policy change to accommodate the changes we've seen in telehealth. So in both cases, what we need is an update at the state and the federal level. And that's what we're trying to do.


ERIN MCCALLISTER: And on the federal level, one of the issues is Medicare, in terms of the reimbursement for Medicare patients and telehealth. Can you talk a little bit about what's being or what isn't being done there, and what can be done to change that?


TOM DASCHLE: Well, it's interesting. We've done a number of things in recent years to try to encourage more opportunities for home health and to reduce re-admissions for hospital settings and a number of other things to bring down cost.


What we haven't done to accommodate that is to recognize the value of telehealth and its role in saving costs and improving quality. And that's basically what the alliance is designed to do is to bring people to a real appreciation of the magnitude, the potential, the real savings, and the improvement in quality that we can bring about by changing and bringing up to date the regulatory environment.


ERIN MCCALLISTER: And one of the things that you mentioned, I mean, it's all about cost today when we debate healthcare. You can't talk about healthcare without talking about cost. And it, to me, seems like a no brainer that something like telehealth -- where you don't have to travel to see your doctor, where you don't have to pay facility fees, things like that -- that Telehealth could possibly bring down healthcare costs. So what's really standing in the way here to that?


TOM DASCHLE: That's a great question, Erin. And I think the basic answer is that on a per patient basis, there's no doubt you can bring down cost, in some cases, very dramatically. But what the budgetary sources and scores are concerned about is the dramatic increase in utilization as a result of the ease of use and the opportunities that telehealth presents. In other words, the ubiquity of care may actually see an increase overall in costs, even though on a per person, per patient basis, you'll see a decline.


ERIN MCCALLISTER: And then one last question before we wrap up is we were talking about reimbursement, but also it seems like there's going to be somewhat of a behavior change as well that needs to really take effect. Do you see that as also an issue that is still out there that needs to be dealt with?


TOM DASCHLE: Well, I think there's no question that behavioral changes are something that we're going to have to take into account. Clearly, as we make these dramatic transformations in the way care is provided, the way care is sought, the ease with which care can be offered in telehealth settings, behavioral circumstances are going to change with it. We have to make sure that we can accommodate those behavioral circumstances as we go forward.


ERIN MCCALLISTER: So how much longer will it be until your doctor is just a mouse click away? We'll be back to talk with Senator Daschle about that.


NARRATOR: Every month, BioCentury This Week will feature profiles in innovation, a special segment highlighting the stories of innovators whose work is improving lives and transforming the world of healthcare.




ERIN MCCALLISTER: We're looking at the future of telehealth, concluding our discussion today with Senator Tom Daschle. Senator, when we left off we were talking more about the federal issues, and you'd also mentioned that there's some state related issues. Licensing, in particular. Can you talk a little bit more about that, and maybe what can be done on that topic?


TOM DASCHLE: Well, I think a lot of states obviously are recognizing now the tremendous potential that telehealth can bring. But you still have a lot of, maybe I would call traditional thinking among some of the providers, and some of the lawmakers in many states, who believe that some sort of face-to-face requirements are still imperative as care is provided.


I think that's evolving. About 20 states now have begun to consider ways with which to improve the regulatory process and change the licensing procedures. But it basically comes down to what constitutes good care today, and can telehealth fill a void that in many cases is so critical, especially in home health settings?


ERIN MCCALLISTER: Mm-hm. And when we're talking about the licensing issues, say you have a license to practice in New Jersey, and you have a patient that wants to do telehealth in California, but you're not licensed there. So that --


TOM DASCHLE: That's precisely the challenge. It's to allow providers to offer care regardless of setting. If you are a South Dakotan, my home state, you ought to have access to the best care, because telehealth is really the death of distance. It's the death of -- it really doesn't matter where you live.


You can get that care because it's like being in the room, regardless of where the provider may be. Licensing doesn't take into account that death of distance, as it should. And that's really what states are trying to grapple with today.


Right. And so is your group doing anything on a state-by-state level, or are you sort of trying to tackle it more at the federal level to begin with, and then --


TOM DASCHLE:  That's a great question. Actually, we're trying to do both. We realize that certainly at the federal level, there's a lot of need for modernization, but on a state-by-state basis as well, what we want to do is find as many good models at the state level that we hope other states will look at as they consider licensing in the regulatory environment.


And we're making some progress in that regard, but it really does require, in some instances, a state-by-state approach to ensure that these issues can be dealt with effectively.


ERIN MCCALLISTER: Right. And one of the big hangups for states is this notion of safety, right? But a patient could just as easily get in a car accident driving across state lines to go visit that doctor, rather than sitting in their home, you know?


TOM DASCHLE: Well, I think in many, many cases, we can clearly demonstrate that telehealth is not only something that saves resources, saves money, but it actually improves quality, because it improves access. It improves the regularity of good care.


And this is especially true for chronic illness, where you have people who need chronic illness care, but can't get it because they don't have access, because of the distance or because of the cost. So many other factors involved are really addressed with telehealth and connected care.


ERIN MCCALLISTER: And in terms of getting more people on board, the VA has been using telehealth for many years now, and other, Kaiser Permanente, and WellPoint has its telehealth. How important is it to sort of get all the players involved to take it? At what point do you reach a critical mass of energy behind this issue?


TOM DASCHLE: Well, that's really the issue. There are clear demonstrations where telehealth has already shown to have great value, and you mentioned several good ones. Kaiser, WellPoint, the VA. I mean, those are excellent examples of how well it's worked already. But what we need to do is to get all players, and that's really the value of our alliance.


We call it the Connected Care Alliance, and it's designed to bring all the players together at one table to talk through the issues and the challenges, and hopefully convince even greater numbers of people of the value of this going forward. This is such a transformational time, and we're going to be able to get this job done with that alliance.


ERIN MCCALLISTER: OK. And then one last question real quick, how soon before anyone could access telehealth? What do you think?


TOM DASCHLE: I think within five years, most people are going to have that opportunity.


ERIN MCCALLISTER: All right. Great. Well, that's our show for this week. I'd like to thank my guests, Senator Tom's Daschle, John Jesser, and Dr. Ray Dorsey. Remember to share your thoughts about today's show on Twitter. Join the conversation by using the hashtag #BioCenturyTV. For Steve Usdin, I'm Erin McCallister. Thanks for watching.