Telemedicine’s woes

High Plains Rural Health Network fights for life

Three months ago, Alan Blumenkamp traveled from his home in Sydney, Neb., to Poudre Valley Hospital in Fort Collins for surgery to repair a torn ligament in his wrist and alleviate a painful case of carpal tunnel syndrome.

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Dr. Lee Gordon, a hand and microsurgeon, did the work, and Blumenkamp returned home.

He has had several follow-up visits since then, but rather than make the six-hour round trip to see Dr. Gordon in person, Blumenkamp, an employee of Sydney’s Memorial Health Center, sees his doctor via televideo.

Dr. Gordon can analyze information provided by Blumenkamp’s physical therapist, see and talk with his patient, even use tight camera angles to examine the injured area, and the exam is done in about 15 minutes.

The electronic connection between Dr. Gordon and his patient is made possible by the High Plains Rural Health Network. The Fort Morgan-based nonprofit was established six years ago to facilitate health-care delivery to underserved, rural areas and now encompasses eight urban hospitals including Columbia Presbyterian St. Luke’s Medical Center; Centura Health hospitals, St. Anthony Central and Penrose/St. Francis; PVH; and North Colorado Medical Center in Greeley. The network also includes 16 rural sites and several other health organizations. The open access system extends from Pueblo to Sidney, Neb., and from Atwood, Kan., to Vail, and allows all sites to interact through two-way video and two-way audio.

The network began as a cooperative buying group offering purchasing and billing services to rural health facilities. It was one of almost 50 organizations around the country that received federal funding in 1993 to build and manage a telemedicine network. With $1.5 million from the Department of Health and Human Services, $600,000 from the Department of Agriculture and $800,000 from the Public Utilities Commission, the High Plains Rural Health Network set about inviting regional hospitals to become members.

The network has developed a large and diverse membership, and has become one of the largest telemedicine networks in the country. However, funds are dwindling, and although the network has applied to the Department of Health and Human Services’ Office of Rural Health Policy for another three-year grant, more money will not ensure the network’s survival in its current form.

“The future of the network is very questionable,´ said Linda Roth, administrator at Keefe Memorial Hospital and the network’s chairman of the board. “As much as we want to go forward with the same service we’ve been providing, we have to look at a contingency plan if funding isn’t available.”

High Plains spends almost $800,000 a year on the rental and maintenance of T1 telephone lines, training, equipment upgrades and customization, round-the-clock technical support and scheduling of all audio/video connections for its membership. Members pay annual dues for these services: $15,000 for urban sites and $2,000 for rural sites. But to continue existing services along with other educational and advocacy programs, Roth said the network needs a major buy-in on the part of the urban hospitals, reimbursement agreements from the insurance companies and a means to make transmission charges affordable and keep the service feasible.

Sharing the pie

Before he had access to telemedicine, Dr. Gordon traveled to Sterling once a month to see patients. Now he teleconferences with his rural patients. He saves the travel time and is still able to meet his patients “face to face” and help maintain the relationship between PVH and Sterling Regional Medical Center.

Such relationships are important to urban hospitals, which seek to draw more referrals from rural locales, and to rural hospitals, which often count on their urban partners for financial and technological support.

“There’s a fine line between when a patient gets moved from a rural hospital to a tertiary-care hospital, explained Peter Caplan, executive director of High Plains. “The idea behind the network was to give rural hospitals an opportunity to keep patients in town, but if a patient must travel, they are likely to visit the hub site that teleconferences most often with their rural facility.

“Our network has a unique structure that includes several tertiary hospitals with spokes to rural facilities, and this creates advantages and disadvantages,” Caplan said. “Typically, a network has one large medical school or urban center which connects to 12 or so rural sites, which take advantage of the hub’s technology and financial strength. We have eight urban sites, and they’re all sworn competitors. Now the hubs are being asked to contribute more money, and they want something back – greater loyalty from the rural sites in the form of more referrals. What was our social mission to serve patients in rural areas has also become an economic opportunity for the urban sites that invest in the network.”

A shared concern among network advocates is that the urban hospitals will not see the benefit in making a cooperative effort to maintain the network’s open architecture and will opt to carve out their rural affiliations and create exclusive televideo connections.

Caplan believes that another grant will sustain the network’s ability to convince the urban sites that it is in their best interest to support the network and share the pie, but signs of divisiveness are already evident.

Caplan said the network has asked Centura to resign its membership because the hospital group has applied for the same grant that High Plains has requested, in order to expand its own network.

Vera Kloepfer, director of telehealth for Centura, said the company’s move is not adversarial.

“We’ve applied for and received several grants for our telemedicine program,” she said. “Centura serves a significant number of rural hospitals outside of the High Plains network, and we intend to serve the whole state. As part of our mission to provide health care to rural areas, we want all the areas we serve to have the opportunity to participate in telemedicine. High Plains didn’t want to add new sites, so geographically, they couldn’t provide the service we needed.”

Another concern is that some urban hospital bean counters may be reluctant to lend more support to the network until doctors tell them telemedicine is something they can’t live without. And Caplan admits that many doctors remain ambivalent.

“The invitation to join the network went out to the hospitals, but we didn’t directly invite the doctors to be involved,” Caplan said. “We’ve also experienced some transmission problems, and as a result, there’s been a collective yawn on the part of many docs – especially in the rural areas. Of the 90 or so doctors in Fort Morgan, only about 10 have used the network.”

Doctors at PVH use the system more than any others in the network. The hospital has conducted 340 clinical consultations and echocardiograms in the past 18 months and is on track for 500 sessions this year, said Steven Mecklenburg, telemedicine coordinator for PVH. Mecklenburg attributes the program’s success to doctors’ enthusiasm, the hospitals emphasis on rural health care and his availability as a full-time employee to train system users.

“This is a useful and reliable system and we’re really committed to it,” he said. “This is the future of medicine – transporting information, not people.”

Mecklenburg added that PVH is supportive of the network’s open architecture, but the hospital is prepared to continue its telemedicine program with or without it.

Reimbursement for telemedicine

At this point, most insurance companies in Colorado have not established policies to reimburse primary-care doctors or specialists for telemedicine conferences with patients.

Though some insurers are inching toward reimbursement policies, they remain unconvinced that televideo is a viable substitute for a visit to the doctor in person.

“We’re trying to determine telemedicine’s efficacy, quality, patient satisfaction and cost effectiveness before we make a decision on reimbursement,´ said Jim Allen, rural contracting manager for PacifiCare, formerly FHP Health Care. “Potentially, we will reimburse, but we’re looking at it on a case-by-case basis.

“We need to determine which diagnoses or specialty types should be using this equipment. And we don’t want to lose interaction between patient and provider or see telemedicine as a substitute for providers going to rural areas.”

Allen said the company is conducting research on the issue, and he expects it to make a decision soon.

“There is pressure from the network sites looking to recoup their investment, and High Plains is looking for us to pay a set fee, but so far there hasn’t been a cry from providers to uphold that request,” he said. “We’re not dragging our feet, but we didn’t request the investment, and now we’re being asked to contribute to the cost.”

Blue Cross Blue Shield is currently working up an arrangement to reimburse specialists for telemedicine consultations, said Karla Johnson, who handles provider integration for the company. But it is not certain when the company’s policy will be up and running.

“Telemedicine reimbursement will work like a regular HMO [health-maintenance organization] reimbursement,” Johnson said. “If the primary-care physician thinks its appropriate for the patient to consult with a specialist using telemedicine and sets up the consultation within our network, then our plan is to reimburse the specialist.”

“We support telemedicine,” Johnson added, “but we still have some questions about licensure, credentialing and the costs involved.”

For Dr. Gordon, the issue of reimbursement is not paramount. Most of his telemedicine consultations are follow-up visits covered in the cost of the surgery, and he considers the system to be a good marketing tool.

“It will only pay dividends,” Gordon said. “If surgery is necessary, I’ll be paid, and if it’s not, there’s still a feeling of good will.”

“Of our 300 doctors, 140 have signed up to provide this service for free,” Mecklenburg added. “It’s a huge gesture of good will, and it’s a powerful medium — when all else fails those patients come to PVH.”

Caplan said that one organization that has agreed to reimburse for telemedicine is the Colorado Compensation Insurance Authority, but without an official policy to reimburse doctors across the board, relatively few physicians will use the network, and the network will continue to struggle.

The cost to telecommunicate

Telecommunications technology has been used to exchange medical information between sites via video since the 1960s. Today, virtually every state has a telemedicine network, and the technology is better than ever before.

It’s also expensive.

High costs associated with transmission, maintenance and overhead within the High Plains network average out to a whopping $1,000 or more per televideo consultation, Caplan said.

One way to defray such high costs is to increase use of the system by finding other functions for the technology. High Plains encourages members to use their televideo systems for administrative and educational purposes in addition to clinical uses.

When NCMC joined the High Plains network three months ago, along with McKee Medical Center, North Colorado Family Medicine residency program, Wray Community Hospital and Yuma District Hospital, the number of Western Plains Health Network members linked through televideo rose to nine.

Richard Wiest, director of outreach services for Western Plains, said his group initiated its involvement with the idea that it would use televideo primarily for administrative and educational purposes.

“We use televideo for meetings, sharing information and as a way to keep people off the road,” he said. “Some clinical use is expected, but we think the technology has yet to be proven as a widely-accepted way to treat patients.”

Greg Smith, president of Rural Health Futures, believes that affordable televideo for rural health facilities must involve the whole community. His company, which assists rural communities with health issues, is working on a project in Pratt, Kan., which will make the city’s televideo site available to a wide variety of professionals: doctors, lawyers, and others, who will share the cost of the system.

Perhaps the most promising hope for a reduction in transmission charges lies in the Telecommunications Act of 1996, which makes provisions for and requires discounted rates for schools, libraries and rural health providers.

In addition, telecommunications deregulation may boost competition for telemedicine business and make it more feasible. As network chairperson Linda Roth pointed out, “It doesn’t matter if the doctors get paid and everyone’s happy. If the transmission charges aren’t affordable, the equipment will sit and gather dust.”