Editorial Affordable Care Act and Telemedicine

Ronald C. Merrell, MD, FATA, and Charles R. Doarn, MBA, FATA Editors-in-Chief


he Patient Protection and Affordable Care Act (P.L.111-148) was signed into law on March 23, 2010. We are now, therefore, 5 years into the most sweeping reform in healthcare in U.S. history. The law changes so many things and assigns to the federal government many responsibilities previously distributed among the states, health industry, insurance industries, charitable activities, and individual initiatives, including those of patients. It would be reasonable for someone not familiar with the United States to ask what has taken us so long to move toward this reform. Please know that the U.S. Constitution does not guarantee healthcare to its citizens. At the time the Constitution was written in the 18th Century, no one would have thought of putting in a guarantee of such a right. Later constitutions routinely recognize the right of its citizens to healthcare but not the founding documents of the United States, when mandating healthcare would have been about as unlikely as such a provision in the Magna Carta. The current reality of healthcare in the United States is the outcome of consumer demand, commercial and charitable response, and a slow evolution of a very complex but may we say fabulously successful, if haphazard, healthcare industry. Please know that there is no Ministry of Health in the United States. We move to reform from a very different perspective than other nations, but it seems we are doing so now! With the U.S. government reaching almost equity in expenditure with the private sector in a loose collection of fractional coverage legislation, the need for a national framework was overdue. Now that does not mean that our reform looks like that of any other nation! It is not a national health service. It is not a single payer system. It is not a federal health endeavor. It is a reasonable response to reform what has slowly grown in the United States over centuries and now badly needs coherence and practicality. In essence, the law for reform declares at long last that U.S. citizens must have health insurance. That insurance may be provided by expansion of the Medicaid program, individual but regulated health policies, or health exchanges with or without federal subsidy. Health insurance is mandated to provide basic preventive and other health benefits and may not enjoy excessive profits. Previously, regulation of health insurance was done state by state. Central definitions and regulation make health insurance more of a consistent and national effort. Employers are tasked with enrollment if they have a certain number of employees. Individuals who choose not to have health insurance will be fined by the U.S. government. This was upheld by the U.S. Supreme Court in National Federation of Independent

DOI: 10.1089/tmj.2015.9995

Business v. Sebelius on June 28, 2012 (Case Filing 11-393). The Affordable Care Act was ruled a tax and not a mandate. The details of the Affordable Care Act can be found in 2,000 pages of the legislation and a proliferating mass of regulatory information. Understanding the legislation has created a new consulting industry, and interpreting the legislation will occupy all segments of opinion about the legislation for the coming decades. More than 20 million people now have insurance, and the insurance of many others has been altered to the benefit of the subscriber. The law has been implemented in long phases and is not yet fully in place. However, the landscape of U.S. healthcare is drastically changed. Unlike previous innovations in the United States such as Social Security, Medicare, and Medicaid, the law for the most part has had the approbation of American medicine, hospitals, and insurance companies. Certainly, the law has prompted massive protest, criticism, and predictions of doom not unlike previous game-changing legislation related to health. However, the law seems to be permanent, and the United States is changing rather than awaiting the demise of the legislation. The sudden increase in insured patients was to reduce the uninsured burden on hospitals and providers, and thus limit cost shifting or unbalanced exposure for the care of the uninsured. A sudden increase in health insurance was expected to provide a great increase in visits to medical facilities. The changes will certainly entail greater and greater amalgamation of health services into accountable care organizations and evolving methods to control healthcare costs, while making access optimal and sufficient to serve the population. The amount of information and the portability of health services were, to say the least, daunting.

The Role of Telemedicine From the time of consideration of this massive reform, the role of telemedicine to deliver services has been proposed as a mitigating factor. It is appropriate to consider the rolling out of this massive reform as an experiment, and that implies moving from assumptions to confirmed outcomes that will guide subsequent evolution of U.S. healthcare. The telemedicine community has begun this exercise in experiment and analysis. Myers and Lieberman1 reported on the mandates for reform with reference to telemental health and primary care. Mental health services in the United States are already stretched painfully thin, and private insurance has been reluctant to press forward with comprehensive services. Although reform has changed this paradigm, the capacity of mental health services is simply inadequate without invoking the information and direct service resource of telemedicine. The impact of reform has been nicely outlined in terms of its potential by Weinstein et al.2 Opportunities for

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telemedicine include rapidly expanding reimbursement and broadband telecommunication to the furthest reaches of the United States. Reimbursement by private insurance is mandated by legislation in over 20 of the 50 states. Medicare and Medicaid reimbursement is very much on track. The American Telemedicine Association has been tireless and highly effective in making telemedicine a fully functional and funded tool in health reform. Although telemedicine is not directly addressed in the parent legislation, it is an obvious and essential tool in moving forward. For example, the inclusion of telemedicine programs in accountable care organizations has already been recognized.3 Recently Rashid Bashshur and colleagues performed an exhaustive survey of telemedicine and chronic disease management.4 This article has been widely read in the U.S. Congress and among health planners, and its download rate is among the highest of anything this Journal has ever published. It is time to study the impact of telemedicine on the Affordable Care Act, and vice versa. What is working, and what is not? What should we be doing better? What do we need to make telemedicine a better tool while the regulations of the law are in evolution and flexible? Many of you have strong ideas in regard to these questions. We invite the telemedicine community to continue to be analytical and scientific. We urge you to come forth with outcomes and solid data to inform your colleagues as they struggle toward best practices for telemedicine in an era of health reform in the United States. We ask that you bring forth your data and thoughtful interpretations to inform government, health agencies, and healthcare decision makers in hospitals, insurance companies, and practitioners to make this reform

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the success many have hoped to realize. We believe we are greatly aided in U.S. telemedicine by the experience of our broad author group in other healthcare systems abroad, and we believe your work in the area of telemedicine and health reform will be highly pertinent to the global telemedicine community. We are in no way suffering for lack of submissions by our wonderful authors. However, after these first years of reform in the United States, there should be a growing treasure of data in your programs that deserve a voice, and we encourage you to make that voice your journal. Something monumental is happening in U.S. healthcare. Telemedicine is without doubt a huge part of that process. Please enrich our pages and the knowledge of your colleagues by marshaling your experience into sound references to make us all better in the telemedicine field that we love.

REFERENCES 1. Myers KM, Lieberman D. Telemental health: Responding to mandates for reform in primary healthcare. Telemed J E Health 2013;19:438–443. 2. Weinstein RS, Lopez AM, Joseph BA, Erps KA, Holcomb M, Barker GP, Krupinski EA. Telemedicine, telehealth, and mobile health applications that work: Opportunities and barriers. Am J Med 2104;127:183–187. 3. Wood D. The move to accountable care organizations includes telemedicine. Telemed J E Health 2011;17:237–240. 4. Bashshur R. Shannon GW, Smith BR, Alverson DC, Antoniotti N, Barsan WG, Bashshur N, Brown EM, Coye MJ, Doarn CR, Ferguson S, Grigsby J, Krupinski EA, Kvedar JC, Linkous J, Merrell RC, Nesbitt T, Poropatich R, Rheuban KS, Sanders JH, Watson AR, Weinstein RS, Yellowlees P. The empirical foundations of telemedicine interventions for chronic disease management. Telemed J E Health 2014;20:769–800.

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