As virtual doctor visits take off, debate over who should pay heats up
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Pulse of Longwood takes you inside one of the nation’s largest hubs of hospitals and biomedical research.

When is a video chat with a doctor equivalent to an office visit?

State legislators across the US have been grappling with that question as hospitals press for insurance companies to fully cover virtual appointments — and insurers balk at those demands.

But the political wrangling, including a heated debate now at the Massachusetts statehouse, hasn’t stopped the growth of telemedicine.

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And so, while three kids jumped and squealed in the house, Erica Jensen, a 22-year-old nanny, opened her iPad the other day and beamed into her doctor’s office by video. She came away with instructions for getting her diabetes under control — without having to wade through Boston traffic or take time off from her job.

The consultation was part of a new effort at Boston’s Brigham and Women’s Hospital to let patients make “virtual visits.”

So far, the Brigham has not been reimbursed for its video experiments, said Dr. Adam Licurse, medical director of Brigham and Women’s Physicians Organization, which oversees telehealth.

Brigham doctors see up to 10 patients per week by video, and will soon see up to 100 a week as the practice spreads to different specialties, said Licurse. The virtual visits aren’t offered to every patient, just to those who have already met their doctor in person and need a follow-up that does not require a physical exam.

Jensen, for instance, uses her video chats with Brigham endocrinologist Dr. Marie McDonnell to discuss her latest insulin numbers. She said she loves the convenience: “It really is like FaceTiming with a friend.”

McDonnell, who sees about five patients a month by video, said they seem to have better attendance online. At the hospital, she said, “many patients just don’t show up. It’s too overwhelming. Then all of their care slowly unravels when you can’t maintain contact.”

Not all hospitals offer patients a telemedicine option, but many are trying it out.

Joslin Diabetes Center doctors use virtual visits for follow-up appointments with out-of-state patients, and would do more if insurance paid for them, said spokesman Jeff Bright.

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At Boston Children’s Hospital, Dr. David Casavant, who treats patients on home ventilators, said he once used a video app to examine a patient who was having a coughing fit, and ended up saving the family an ambulance ride.

Cambridge Health Alliance, a safety net hospital with many low-income patients, has started a grant-funded telederm program in which primary care doctors snap photos of rashes and send them to dermatologists, who pledge to get back within 24 hours. Doctors have made 550 consultations that way, according to dermatology chief Dr. Robert Stavert. He said in two-thirds of cases, patients have clear problems, such as psoriasis or hives, that can be treated without requiring them to come into the clinic.

That’s especially helpful, Stavert said, because patients in Boston have poor access to skin care: They wait an average of 72 days for an appointment with a dermatologist, one study found.

The Massachusetts Hospital Association has organized a coalition to support House Bill 267, which would require private payers to reimburse telemedicine at the same level as in-person services. The bill would ensure all Medicaid and state employee plans cover telemedicine services, including patient-to-doctor and doctor-to-doctor consultations. And it would allow doctors to remotely treat patients in different states.

Across the country, 29 states have some type of parity law requiring coverage of telemedicine services, though not all of them require equal reimbursement rates, according to the American Telemedicine Association. States also define “telemedicine” in different ways: under the Massachusetts bill, it would include services transmitted by video, audio, or other electronic communication.

State Representative John Scibak (D-South Hadley), a former hospital vice president who sponsored the bill, said it aims in part to reduce the time, money, and stress it takes for patients to get to the hospital.

But the Massachusetts Association of Health Plans, which represents 17 private plans, argues that the bill is far too broad — and would allow doctors to start billing even for minor services, such as a phone call.

The bill “would undermine the premise that telemedicine will ultimately lead to savings for providers and consumers,” said Eric Linzer, a spokesman for the association.

Many private insurers are already working with hospitals and doctors’ offices to cover specific telemedicine procedures, and it’s better to let the marketplace figure that out rather than impose a “one-size-fits-all” law, Linzer added.

Blue Cross Blue Shield of Massachusetts, which launched a telehealth benefit in January, now offers to reimburse for video consultations with a patient’s own doctor. And it lets patients virtually tap into a national network of on-call doctors through a company called American Well. But the insurer opposes HB 267 on the grounds that telemedicine is cheaper to implement than in-person visits, so the reimbursement rates shouldn’t be the same, said Gregory LeGrow, senior director of technology engagement solutions.

Michael Sroczynski, the hospital association’s vice president of government advocacy, countered that hospital overhead costs are mostly labor-related and don’t disappear with telemedicine.

The state Center for Health Information and Analysis is conducting a cost analysis of the bill, which isn’t expected until summer.

Meanwhile, McDonnell said she and fellow endocrinologist Dr. Emma Morton-Eggleston plan to double the number of patients they see by video. And when the affiliated Faulkner Hospital opens a new diabetes clinic in June, there will be a separate, well-lit room where doctors can virtually connect with patients to manage diabetes, weight, and sleep, she said.

One remaining challenge, McDonnell said, is ensuring patients have peace and quiet on their end. During their visit last week, Jensen got distracted by a crying baby and two kids who started jumping on the couch.

“That’s the only downside to virtual visits,” McDonnell said. You have to “make sure the patient has privacy and attention.”

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