Challenges of Launching a Telehealth Program

Since the launch of NYP OnDemand, a comprehensive suite of telehealth services, in July 2016, it has already become one of NewYork-Presbyterian’s core service offerings. Creating NYP OnDemand led us to identify and address four key challenges that we believe are inherent in the development of any telehealth program by any health system:

• Liability – Does this new model of care either amplify existing or create novel medical practice liabilities?
• Licensure – Because we take care of patients who reside in many different states, under what circumstances would our physicians need to be licensed in other states for telehealth purposes?
• Reimbursement – Our payer contracts did not address care delivered virtually, and Medicare only reimburses a limited set of telehealth services delivered in certain rural areas. How can providers get paid for telehealth?
• Workflow – Is telehealth just like any other model of care delivery, or do we need to rethink how our providers deliver care?

We tackled these questions through a combination of research (including the assistance of our legal and regulatory departments) and conversations with peers who had experience in the field.

Liability.  The question around telehealth liability arose when we contemplated how clinicians would interact with patients virtually. While we believed that our clinicians would be able to provide high-quality virtual care (particularly since it has become common practice for clinicians to interact with their patients informally via text, email, and video chat), we did not know whether these interactions had a potential for greater legal liability as compared to in-person visits. This turned out to be the simplest issue to address — our malpractice carrier confirmed that our clinicians would be covered as long as they were practicing within the scope of their license. We cannot say whether all carriers offer such coverage, so we encourage other health systems to check before launching a telehealth program.

Licensure.  Licensure presented a number of challenging issues. In a traditional context, clinicians must be licensed in the state in which they practice medicine — but state medical licensure regulations typically do not anticipate many of the possible scenarios created by telehealth. Two examples are illustrative:

• A physician who is licensed in New York but resides in New Jersey has a telehealth visit from his or her home with a patient who lives in New York.
• A patient residing in New York travels out of state and has a telehealth visit with his or her regular physician, who is located in New York.

We examined these kinds of scenarios, initially focusing on four states that provide our largest volume of patients: New York, New Jersey, Connecticut, and Florida. Unfortunately, after some detailed research (and support from the American Telemedicine Association’s state-by-state guides), we found that regulations vary widely from state to state. This led us to adopt different strategies for each application of telehealth. Our urgent care physicians — a relatively small pool of clinicians — obtained licenses in these four states relatively quickly. Given the larger number of clinicians involved, however, this approach was impractical for follow-up visits, and we consequently limited the geography for this use case.

Reimbursement.  Because establishing a comprehensive telehealth program requires a significant up-front investment in technology, and because we continue to deliver care in a largely fee-for-service environment, reimbursement was a key consideration as we planned NYP OnDemand. We learned, however, that resolving current reimbursement issues is likely to be an evolutionary process. Medicare regulations are clear cut: the program reimburses only a certain set of services delivered via telehealth when the patient is located in an officially designated rural physician shortage area. New York State passed a telehealth parity law addressing Medicaid and commercial insurance around the time that we launched our telehealth program. Though the law took the necessary step of protecting patients, it did not mandate reimbursement parity for providers, and it exempted self-insured employers altogether.

As Telehealth Evolves

While these four challenges can be overcome in launching a successful telehealth program, they require serious consideration. They also demand a flexible approach, recognizing that regulation, practice, and culture will all evolve as telehealth becomes a generally accepted mode of care delivery. Our hope is that this fosters a virtuous circle, whereby increased sharing of best practices on the provider side, and increased awareness and demand on the part of patients, will decrease the challenges associated with launching a program — thereby encouraging greater adoption of telehealth by patients and providers alike.