Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, June 23, 2016

Virtually Certified

A while back, I wrote about HealthTap, a platform that allows people to ask doctors questions in almost real time. The company was also developing a system for virtual care, and I recently received an email suggesting I take an online course, worth 2 CME credits, to be certified in said virtual care.

I was curious about the progress in this field, so I did take the course, and am now officially certified. I also accidentally clicked an  "okay" button, thinking it would allow me to print out my certificates. But it was the wrong button. The button I wanted said, "certificate only", but I didn't see it in time. The "okay" button indicated that I was allowing myself to be part of the HealthTap network of physicians. I didn't really want that, but I suppose it doesn't matter since I'm not going to do anything with it. So watch out for this if you decide to try it.

What I was mainly interested in, in the course, were the legal and regulatory issues related to virtual care. And I did learn a couple things. For instance, you do need to be licensed in your patient's state in order to provide virtual care. I don't know if that means the state where the patient resides, or just the state the patient is in when seeing you. I would guess the latter, since I can treat patients, in person, who live in neighboring New Jersey or Connecticut for example, where I'm not licensed, as long as they see me in my New York office.

Incidentally, you don't need to be licensed in any particular state to virtually treat patients outside the US.

The course referenced the Interstate Medical Licensure Compact, which, "Creates a new pathway to expedite the licensing of physicians seeking to practice medicine in multiple states. States participating in the Compact agree to share information with each other and work together in new ways to significantly streamline the licensing process."

A number of states have already enacted legislature that will allow this expedited pathway to proceed, and other states have introduced such legislation. Still others, such as New York, have done neither. One interesting point I noted is that in order to use this expedited system, you need to be primarily licensed in a state that has already enacted the legislature. So if I want to virtually care for patients in Montana, which has enacted this legislature, I can't, because I'm licensed in New York, which hasn't.

That point is irrelevant, though, since there is currently no administrative process for applying for this pathway, although they state that there, "...will be soon."

The video mentioned that there are CPT codes for virtual care, ranging from 99441 for a 5-10 minute telephone Eval/Management consultation, to a 99444 for an online E/M, to a 99446 inter-professional 5-10 minute consult, to a 99490 > 20 minutes of chronic care management. But most virtual care billing is done using the same CPT codes that would be used for a regular office visit, with a GT modifier, e.g. 99213 GT.

Most importantly, 25 states with parity laws, plus Washington DC, have enacted "...legislation requiring private insurers to pay for Virtual Care at the same level as equivalent in-person services, provided the care is deemed medically necessary."

According to this document, in New York, "The law requires telehealth parity under private insurance, Medicaid, and state employee health plans. The law does restrict the patient setting as a condition of payment."

This image depicts which states make it easy to provide virtual care (A is best), and which make it difficult (I'm not sure what the * means):

Aside from that, the course touts the virtues of virtual care, claiming that in some ways, it's superior to in-person care, and giving examples, such as the fact that patients have quicker access to virtual care. They also claim that many, if not most, common complaints can be treated virtually, and a lot of monitoring can be done at a distance, e.g. glucose. In addition, they mention the use of wearable devices for tracking activity, etc., and the up and coming virtual examination tools, like stethoscopes.

The video is careful to note situations which require in-person treatment, such as a wheezing infant, or chest and jaw pain in a 68 year old man.

A bit comical were the presentations. For a company that's promoting care via video-conferencing, they should probably have gotten better people to present in their video. One guy had shifty eyes, another had drooping eyelids and looked like he was falling asleep and forgetting what he needed to say, yet another guy looked like his shoulders were hiked up to the point of having no neck.

While I definitely prefer in-person work, I can see where psychiatry, and especially psychotherapy, are amenable to virtual care, probably more-so than specialties that require a physical examination. But given the regulatory and legal limitations, I'm not ready to go there, yet.

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