Medicine Without Borders

There is only one thing you need to know about telemedicine: location doesn't matter.

The pathologist who examines your blood tests, the radiologist who reads your MRI scan, the internist who orders your prescription or the nurse who reminds you to refill a prescription – none of these providers needs to be in the same room with you. Or in the same city. Or in the same state. Or even in the same country.

Telemedicine could revolutionize the practice of medicine, especially for the chronically ill.

Instead of making a two-hour, round-trip visit to a doctor's office, a diabetic could communicate with her doctor by telephone or email. A nurse practitioner could remind her to conduct a home test by telephone, email or text message. The results of home testing could be sent to a physician electronically. Prescriptions could be ordered electronically, thereby taking advantage of error-reducing software. Test results and medical records could be transported electronically from specialist to specialist. All of these measures could potentially produce more care and better care.

Telemedicine could also revolutionize efforts at cost control.

Just as the widespread use of the Internet lowered seller markups on every product from automobiles to groceries, and just as e-Bay has lowered the resale price of just about everything, telemedicine promises to have a huge impact on health care prices . . . . . . unless . . . . . . unless . . . . . . well, unless no one is actually competing based on price.

In a system of nonprice rationing, telemedicine is not necessarily a boon to cost control. In fact, it could prove to be a disaster. If every Canadian patient had access to free telemedical services, it would bust the global budgets in every Canadian province in the space of a few weeks.

That may explain why the principal obstacles to telemedicine are health insurance companies and government. As buyers of care, these two bureaucracies resist paying for anything other than face-to-face medical encounters for the same reason the Canadian government is likely to be resistant.

As a regulator of care, government has erected another set of obstacles. Did you know that it's illegal for a doctor practicing on the Texas side of Texarkana to treat a patient by phone on the Arkansas side of the same city? Did you know it's illegal for a doctor practicing in East St. Louis (Illinois side) to interpret x-rays taken for a patient treated in west St. Louis (Missouri side). Unless these relics of misguided regulatory excess are repealed, the telemedical marketplace each of us has access to may be limited by the borders of the state in which we live.

The most interesting developments in telemedicine are occurring outside the traditional third-party payment system. For example, more than one million people are subscribers to a nationwide service operated by Teladoc Medical Services of Dallas. They can talk to a doctor by phone, any time day or night. (but pay a fee for each consultation). They can arrange for prescriptions by phone and have their medical records transferred electronically to any doctor of their choice. In most cases people who use the service pay with their own money. In some cases an employer pays the enrollment costs. But health insurers rarely reimburse for the service.

Note: Teladoc is not a government initiated service. It is not connected to any insurer. It is not a RWJ pilot program. It's just the free market at work.



For the NCPA's new study on telemedicine, go to:

Comments (5)

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  1. Bob says:

    This needs to be memorialized in a bronze plaque!!
    When is clinical medicine going to enter the 21st century?
    This message ought to be distributed to every medical society, every board of medical exminers, every physician organization, every doctor, every regulatory organization and every insurance company in the country.

  2. Jason says:

    Koodos John and Bob, You know Teledoc has been great for me and my family, We love it, just the sheer convienence alone is worth the cost. I actualy called Teledoc one Satuday afternoon when my son was complaining of an ear infection and after talking to the doctor within in an hour we were picking up our prescription, and never had to go through the hassle of getting to the doctors office on a saturday when our primary doctors office was closed. How great is that?

  3. Robert White says:

    When I worked at Medicare (HFCA), I worked in the Fraud and Abuse section and I was the telemedicine expert. This was in 1999. At that time the only reason HFCA would not agree to pay for telemedicine is no one can prove that the care was provided. The state of Georia had a system were it provided telemedicine to its prisoners. Because the prisoners didn’t have the same right to privacy as you or I, the state could monitor the use of telemedicine. They set up a gate keeper who controled access to the use of the states system. This was determined to be the only system (at that time) that would work.

  4. David says:

    I have enjoyed receiving your health alerts, so thank you for including me.

    Regarding your comment below stating that insurance companies are an obstacle to telemedicine, I must disagree. Each time I meet with physicians, hospitals, employers and brokers/consultants, the question is posed to the group as to why the “suppliers” (physicians/hospitals) are charging such varying prices for their services in relation to their peers, and why the employer (the ultimate payor) is allowing one of their employees to access an MRI at $2,600, when they can get similar service for $600 in close proximity or access a hospital for a certain procedure with a 3x higher complication rate. And the suppliers are then pushed to think if they are really going to be able to compete as the employers begin demanding value for the varying price point for the services provided.

  5. William Boyles / Friend of John Goodman says:

    I would revise your title to be “Medicine Without Doctors” since the impact of this telemedicine scenario on today’s distribution of medical workflow will be a rebalancing of required task versus the required academic degree and associated fees charged by doctors. The ratio of specialists to primary care in the U.S. versus all other countries will be the first casualty because more than half of the task list of the average specialist could be performed by a nurse or online. If as I believe telemedicine proves to be a catalyst for such a rebalancing, the biggest opposition to telemedicine will come for physicians, not insurers. Like medical tourism (which is also not really about borders), the real threat is to the medical establishment and the real opposition will be the AMA and specialty societies, not consumers.