Telemedicine implementation around the country is improving overall, although some states are bottoming out on their progress, according to the latest state-by-state assessment by the American Telemedicine Association that gives letter grades on their policies around practice standards and payment policies.

The ATA’s report is an update to two state policy reports that identify gaps in coverage, reimbursement, physician practice standards and licensure.

Using data categorized into 13 indicators related to coverage and reimbursement, the report identified “a mix of strides and stagnation in state-based policy despite decades of evidence-based research highlighting positive clinical outcomes and increasing telemedicine utilization,” the authors wrote.

“There is promising news overall for patients, providers, and businesses using telemedicine and other digital health platforms,” Latoya Thomas, director of the ATA’s State Policy Resource Center said in a statement. “These reports show that insurers, state lawmakers and Medicaid agencies see telemedicine, and other digital health platforms, as affordable and convenient solutions to bridge the provider shortage gap and enhance access to quality health care services.”

Many states were actually bumped up a full letter grade, and seven of them adopted policies that improved coverage and reimbursement of telemedicine provided services since last year’s report (Connecticut and Rhode Island even made the massive leap from “F” to “B”). Since the ATA first started grading the states in 2014, ten states have enacted telemedicine parity laws with private insurers.

Overall, the country fared pretty well – as of 2017, all states allow coverage of telemedicine to some degree. Additionally, for the first time since the ATA has been conducting the Coverage and Reimbursement report, all Medicaid agencies cover some form of telemedicine. Twenty-six states have some type of coverage for telehealth under state employee health plans, and more states are passing legislation or seeking federal waivers to cover remote patient monitoring (15 cover services when using store-and-forward technology).

But not everyone is moving ahead. While the number of states with telemedicine parity laws has doubled in the past five years, some states – Delaware, Washington, D.C. and South Carolina – were actually downgraded, with the latter owing to the expiration of a remote patient-monitoring waiver for the decline. Arkansas still maintains a failing grade because it is still the only state that requires an in-person visit in its parity law, although that state has recently taken action towards loosening restrictions around telemedicine. 

“Patients and health care providers are benefitting from policy improvements to existing parity laws, expanded service coverage, and removed statutory and regulatory barriers,” the report states. “While there are some states with exemplary telemedicine policies, lack of enforcement and general awareness have led to a lag in provider participation. Ultimately these pioneering telemedicine reforms have trouble reaching their true potential.”

Looking at specialty services, like mental health and rehabilitation, more states are rising up to meet the need: Fifteen states rank high for coverage of mental and behavioral health, although others, like the lowest-ranking New York, have enacted regulations that restrict the service.
 
Focusing on physician practice standards and licensure, the report found medical boards have moved towards a trend of developing different regulations or guidance for medical practice via telemedicine. They are also removing telepresenter requirements, but becoming more prescriptive in the types of modalities allowed.

“As a result of changing guidance and regulation for telemedicine when compared to in-person practice, more states have improved a letter grade since the report in 2016,” the report states.

In a comparison of the numerous state laws and variations in medical board standards across the country, 21 states averaged the “highest composite grade,” showing a general embrace of telemedicine. Arkansas made the most significant improvement by finally adopting rules allowing license physicians to establish a relationship with a patient via interactive audio-video meetings. Two other states, Florida and Louisiana, earned higher scores, and Michigan moved down a grade.

A majority of states and D.C. are more in middle of the road for improvements though, and Texas still averages the lowest composite score, “suggesting many barriers for telemedicine advancement.”

But, Texas must be given credit where it is due: this week, the longstanding telemedicine saga appeared to finally be winding down as the state medical association and industry members like Teladoc reported that they have reached an agreement, the Houston Chronicle reported.

Republican Charles Schwertner, Chairman of the Texas Senate Health and Human Services Committee, will sponsor the legislation that will serve as a compromise on rules.

The bill, which is expected to come out later this month, would allow doctors and patients to establish a first-time relations with audio visits, so long has the doctor has medical records or images to buttress their assessment to form a diagnosis or treatment.

Teladoc, which offers remote medical visits, sued the Texas Medical Board in state court way back in April 2015, alleging that because the board was made up of practicing doctors with a financial interest in squelching telemedicine, the board's passing of anti-telemedicine legislation constituted a violation of antitrust laws. But the medical board filed a motion asking for the suit to be dismissed on the grounds that there is, in fact, state supervision of the medical board which would make it a state agency under law and therefore immune to suit. When the judge denied the motion, the medical board appealed to the Fifth Circuit court. In October, the Texas Medical Board dropped its appeal in its case against Teladoc.

While the compromise represents progress, it's not over til the legislation is actually passed, but pro-telemedicine groups are optimistic.

“This is significant, and will be a winner for everyone, “ Nora Belcher, executive director of telemedicine trade group Texas e-Healthcare Alliance, said to the Houston Chronicle. “This is going to get us a fair and open market for telemedicine in Texas."