As part of NACo’s 2018-2019 Connecting the Unconnected initiative, a significant opportunity for counties to demonstrate innovative ways to deliver “people-centered” services, maximize government efficiency and ensure responsible stewardship of taxpayer dollars, is through the provision of accessible healthcare.

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• Telemedicine terms and definitions
• Rural Kentucky county teams with co-op to bring telemedicine to veterans 

According to the World Health Organization (WHO), the concept of telemedicine has immense potential to address challenges to providing “accessible, cost-effective, high-quality health care services” on a local, national and global scale. The literal translation of the word telemedicine is “healing at a distance,” and it is otherwise defined as the use of information and communication technologies to deliver health care services in areas where distance is a critical factor, for the purposes of diagnosing, treating and preventing disease and injuries, research and evaluation, and for the continuing education of health care providers.

These services may include primary and specialty care, referrals and the remote monitoring of vital signs, and can be provided by videoconference, email, a mobile device, wireless tools or other modalities.

The science of telemedicine is one of constant evolution, as new advancements in technology arise, and communities adapt to the changing health. However, WHO outlines four essential elements associated with the concept of telemedicine:

• Provide support to healthcare practitioners
• Connect users who are not in the same physical location by transcending geographical barriers
• Use of diverse types of information and communication technologies, and
• Aim to improve health outcomes.

Although the use of telemedicine isn’t a substitute for an in-person medical examination, it is proving to be an effective and convenient means of supplemental care. Research suggests that telemedicine can effectively increase medication adherence, which is directly linked to improved health outcomes. Additionally, it is associated with increased access to care, particularly for people living with chronic conditions such as asthma, diabetes, and heart failure; people living with a mental illness; and those in rural and other traditionally underserved areas.

Providing accessible medical care to rural residents is a definite advantage for counties, given that approximately 70 percent of America’s counties are considered rural, having populations of fewer than 50,000. Medicaid serves as the largest source of public health coverage in rural areas, covering nearly a quarter of all rural residents. Counties deliver Medicaid-eligible services, to include those services that can be classified as telemedicine, as an integral part of the federal-state-local Medicaid partnership.

According to the American Telemedicine Association (ATA), all state Medicaid agencies cover some form of telemedicine services. However, the exact services covered can vary from state to state, and there are associated guidelines and restrictions on the type of service provided, the location of the beneficiary, and the type of healthcare professional providing the service depending on the state’s Medicaid regulations.

The most commonly covered form of telemedicine is live video telemedicine (or video chat). Currently 49 states and Washington, D.C. provide reimbursement for some form of live video in Medicaid fee-for-service. Remote Patient Monitoring (RPM), which allows physicians to monitor a patient’s condition through the collection of physiological parameters such as blood pressure and heart rate, is being held as an up-and-coming telemedicine service, with approximately 20 states now reimbursing for RPM services. Additionally, some states are now covering storeand-forward telemedicine with restriction to certain specialties, and phone consultations. Most states allow any Medicaid beneficiary to be eligible for telemedicine services given that the provider and patient work within the guidelines outlined above.

Federal guidance prompts states to use the inherent flexibility around telemedicine policies to create innovative payment methodologies for services that incorporate this type of technology. States have responded accordingly, with the Center for Connected Health Policy reporting that approximately 160 telehealth-related bills were introduced in 44 states during the 2018 legislative session. Given room for innovation, counties within states like Tennessee, which require reimbursement for telehealth services at rates comparable to in-person care, have started to set up telehealth networks in their area.

Earlier this year, clinics in McKenzie and Tipton counties in Tennessee installed audio-visual digital health technology to enable rural and remote residents to have virtual meetings with specialists from University Clinical Health, a Memphis-based physician group affiliated with the University of Tennessee’s College of Medicine. County residents in the area now have access to specialty physicians such as dermatologists and rheumatologists without ever leaving their community.

Recently, the issue of telehealth has been elevated to the federal level as the nation continues to look for new solutions to combat the opioid crisis. The epidemic shed an urgent light on not only the importance of integrating addiction control with behavioral and psychiatric care, but also the need for connected health platforms that allow providers to work with the patient at any time and place. This has resulted in a number of bills being drafted around addressing individuals with substance use disorders, specifically through the use of telemedicine.

In October, President Donald Trump signed legislation on opioids into law: the SUPPORT for Patients and Communities Act. The legislation contains dozens of measures aimed at improving the federal response to the opioid epidemic, and included key telehealth-related bills that allow for the following provisions:

• Eliminate restrictions on sites at which beneficiaries with substance use disorders can reach telehealth services
• Prompts CMS to provide guidance to states on options for providing telehealth services that address SUD through Medicaid, and
• Incentivizes the use of electronic health records technology by behavioral health providers.

In addition to this piece of legislation, federal agency regulations around the use of telemedicine expands the list of qualified providers. Those that are able to use telemedicine include community mental health and addiction treatment centers; the legislation also allows for greater flexibility for healthcare providers to administer Medication Assisted Treatment to individuals with SUD in remote areas.

Emerging legislation and regulations around the use of telehealth services for Medicaid beneficiaries with SUD is indicative of a broader understanding of the benefits of telehealth and telemedicine technologies. Additionally, increased adoption of telemedicine by state lawmakers and Medicaid agencies signifies the recognition of telemedicine and other digital health platforms as affordable and convenient solutions, creating an opportunity to bridge gaps in accessibility and enhance access to quality health care services for local residents. 

Telemedicine terms and definitions

Telehealth: Telehealth covers services provided by other allied health professionals including community workers, nurses and pharmacists.

Distant/Hub Site: Site at which the physician or other licensed practitioner delivering the services is located at the time the services is provided via telecommunication. Originating/Spoke Site: Location of the Medicaid patient at the time the service is being furnished via a telecommunications system.

Store-and-forward: The exchange of pre-recorded data between two or more individuals at different times (i.e. patient/physician email exchange).

Real Time: Requires the involved individuals to be simultaneously present for immediate exchange of information (i.e. video conferencing).

MHealth: A general term for the use of mobile phones and other wireless technology in medical care.