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Show providers often do not trust urban health care facilities to act in the rural providers' best interest (rural people in general are often quite suspicious of anything that originates from an urban center, and one could argue that they have some very good reasons to feel this way). Telemedicine can be perceived as just another instance of "urban" meddling. Cost to urban specialists: In countries where telemedicine has been a reality for some time (these are primarily countries with state-sponsored health care systems), specialists note a significant drop in the number of rural referrals they receive (Proceedings of the Mayo Telemedicine Symposium, 1993). Given the capitalistic nature of health care in the United States, this could pose a threat to the livelihood of urban specialists who may be struggling financially if more emphasis is given to primary care providers as part of the health care reform process. It is critical that attention be given to the needs of urban specialists so that they are encouraged to participate in telemedical consultations. However, if rural telemedicine becomes a common reality, urban specialists who are not tied into such systems for consultation may lose referrals as a result. In addition, urban specialists will have to adjust to a new way of examining patients. Examining patients remotely is similar but not exactly commensurate with seeing them in person. The urban specialists may feel that they are losing control of their patients if the patient rarely actually sees them face-to-face. Transport: For non-emergency cases, as shown in the opening paragraph, there can be a significant savings to patients in terms of gas, lost time at work, etc., if it can be determined that traveling to an urban center may be avoided. This is particularly true for follow-up care or monitoring chronic non-emergency conditions, for example, a stroke victim's physical rehabilitation progress, mental health, tolerance of medication, and some post-surgical follow-up exams. For emergency cases, most small rural emergency rooms and clinics have very limited treatment capacity. Hence, there is often a question of whether or not to transport a patient. Currently, the accepted protocol is to err on the side of safety and to transport patients if there is any risk that they may need care exceeding the capacity of the rural ER. It is projected that there can be a significant reduction in the number of transports if border-line transport decisions could be clarified by a telemedicine consultation with a qualified physician or ER specialist prior to initiating transport. Community Health: Community members may elect to receive care that they may otherwise have skipped if they had to travel a long distance to obtain it. Treating conditions in their early stages improves the health outcomes for the patient and is less expensive. Convenient, relevant CME: Telemedicine has been shown to be a very effective form of training for rural practitioners and has been formally credited as Continuing Medical Education (CME) in some states. Providing ongoing CME locally through telemedicine consultations and/or formally broadcasting CME courses will save registration, travel costs, time away from work, and locum tenans costs. Treating patients locally: One of the major financial obstacles facing rural hospitals is that many of their potential clients leave the area to obtain care that is not locally available. Telemedicine has the potential to expand the scope of services offered locally. It has been informally estimated that 50% to 80% of rural patients transferred to urban sites could stay if appropriate telemedicine service were available/used. Revenues generated by providing a wider scope of services through telemedicine are conservatively estimated to be $85,000 to $150,000 per year per clinic site (Reid, 1993). Reimbursement Currently, there is no accepted standard for how telemedicine consultations should be reimbursed (Kansas Telemedicine Policy Group -Vol. II, 1993). Telemedicine consultations should be reimbursed in a manner equivalent to face to face consultations. If such reimbursement is lacking, consulting specialists will be reluctant to participate in this system. The Health Care Financing Administration (HCFA) telemedicine reimbursement policy for Medicare/Medicaid is limited to reimbursement for reading transmitted diagnostic images (e.g., x-rays). HCFA will reimburse for specialist consultation if the specialist(s), the patient, and the referring practitioner are face to face during the consultation, and a report is produced. Currently, the HCFA Regional Medical Director has the authority to decide whether two-way interactive video constitutes a "face to face" consultation, i.e., whether it will be a reimbursable service. Currently, only Utah's Health: An Annual Review 1994 99 |