Telemedicine has made strides in Indiana since the state passed its first major piece of legislation in 2015, regulating the new technology and requiring private payers and Medicaid to cover telehealth services.

Today, more hospitals and providers are offering consultations and services through virtual visits than ever before, and more rural Hoosiers are tapping into the convenience of talking to a physician through a computer or cellphone rather than potentially driving an hour to the nearest clinic.

A case in point is Community Health Network, which has nine hospitals in the state and launched its telehealth services in late 2017. Since then, the number of patients using the service has more than doubled from around 30 visits a month to around 70. This month, 130 patients will use the network’s telemedicine service.

But Allison Orwig, project coordinator for the Indiana Telehealth Network, a program administered through the Indiana Rural Health Association, said while telemedicine is growing, roadblocks still exist in getting it out to the rural parts of the state, where access to doctors and medical specialists is severely limited.

“Telemedicine is expanding massively, but when you talk about getting it all the way out to people’s homes, that’s the last piece of it,” she said. “It’s expanding to clinics and schools and jails pretty darn quick. But that last-mile connection into people’s physical homes is still a ways off.”

And the biggest reasons for that boils down to two problems: internet access and insurance billing.

‘Woefully inadequate’

Orwig said talking to a doctor online doesn’t require a patient or provider to have screaming-fast internet speeds. But it’s a different story when it comes to some types of telemedicine, such as interactive videoconferencing technology created to treat acute stroke patients.

“It’s extremely, extremely time sensitive, and having inadequate internet speeds or unreliable services can be a major barrier,” she said.

But the number of clinics and medical offices that have access to those kinds of speeds is alarmingly low. Orwig estimated around 75% of rural providers need faster internet speeds to fully utilize telemedicine services to treat patients. She said she receives calls routinely from providers who upgrade their internet service and find they need faster speeds just months later.

“That happens all the time,” Orwig said. “That’s not just a theoretical. That happens consistently.”

The expansion of high-speed internet to rural hospitals has grown by leaps and bounds in the last decade, thanks to the Indiana Telehealth Network, which received $16 million in 2008 from the Federal Communications Commission.

Since then, that money has helped pay for the installation of more than 260 miles of fiber-optic cable to provide blazing fast speeds to some of the most remote hospitals in Indiana.

But newer and more advanced telemedicine services require ever faster internet speeds to which most rural providers don’t have access.

“The speeds that are available at some facilities are woefully inadequate,” Orwig said. “... Only about a quarter of our participates in the telehealth network say, ‘We have everything we need.’ At this point, most providers are getting speeds that they need just to get by, or just what they can afford.”

It’s the same story for some rural residents, who don’t have access to the kind of broadband internet required to use newer telemedicine services.

That’s changing as state officials make a major push to expand high-speed internet across Indiana, including a $100 million investment as part of Gov. Eric Holcomb’s Next Level Connections infrastructure program.

Today, 88% of Hoosiers have access to basic broadband speeds. But the ones who don’t are the ones who likely live far away from a hospital or clinic and have the most need for telehealth services, Orwig said.

“Almost everybody has some sort of internet access,” she said, “Is it adequate access? Absolutely not. There are still tons of spots around the state where internet access is not adequate or reliable at all.”

‘Biggest hurdle’

Hoy Garvin, executive director over Community Health Network’s telemedicine service, tells the story of an Indiana man driving to Tennessee for a conference when he suddenly felt ill and pulled off to the side of the interstate.

The man grabbed his phone and immediately had access to a teleconference with a doctor, who diagnosed him and called in his prescription to a nearby pharmacy. Within 20 minutes, the man had picked up his antibiotics and was back on the road.

Garvin said that’s the kind of convenience and efficiency that telemedicine can provide. But it’s a service that many people avoid using for one reason: Their insurance won’t cover it.

In Indiana, neither Medicaid nor Medicare will cover a telemedicine visit unless it’s done at a designated site approved by the state. Those locations include hospitals, rural health clinics and community mental health centers.

But for patients who want to use telehealth services at home or somewhere other than a state-designated site, the only option is to pay out-of-pocket.

Becky Sanders, senior director of the Indiana Rural Health Association and the Upper Midwest Telehealth Resource Center, said some private insurance in the state will cover costs for very select telehealth uses, but the vast majority of services require the patient to pay for it themselves.

She said inability for providers to bill Medicaid or Medicare stems from federal legislation that lags behind the quickly evolving telemedicine industry, and it’s put a damper on expanding telemedicine services to rural Indiana.

“At this point, the billing issue is probably the biggest single hurdle to everyone having access in their own home,” Sanders said. “... If you pay out of pocket, these services would be available to you, but there’s not many people who can do that.”

Currently, just 12 states recognize a patient’s home as an originating site that would allow providers to bill for insurance, and Indiana isn’t one of them.

Community Health Network’s Garvin said in states that allow private insurance to bill for in-home telehealth, the service has grown by leaps in bounds.

He said one health network on the West Coast has around 10,000 patients a year use its telemedicine services, and around 85% of those are covered or reimbursed through insurance. The rest pay out of pocket.

Garvin said that indicates that if insurance companies were allowed to pay in Indiana, telemedicine would see a huge spike in users.

“You can see that if people have the option to use their insurance and be at home for a visit and skip the waiting room, they’ll do it,” he said. “I’d think we’d see an adoption increase similar to the coasts if insurance companies were helping the Midwest like they are the East and West Coasts … I know we’d see an uptick and increase.”

Andrew VanZee, vice president at Indiana Hospital Association, said many major health networks across the state are coming up with cash-pay solutions to get around the inability to bill insurance so they can offer telehealth services people want.

Garvin said Community Health Network charges a flat $49 fee for telemedicine visits, either via computer or phone, for consultations regarding basic health issues. But even that can be a barrier for some rural residents.

“Sometimes the folks that live in rural Indiana don’t have access to those means, so $49 is about as good as we can do,” he said. “It’s a competitive price throughout the state, but we’re waiting for payers to catch up in this part of the market.”

But new federal legislation could go a long way in solving the insurance billing issue holding telemedicine back in Indiana.

The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act was introduced in the U.S. Senate in late October. The bipartisan legislation has since been referred to the Senate Finance Committee.

The bill would require insurance to cover in-home telehealth visits for mental health services and lifts the geographic restriction for some sites offering emergency medical care.

It also requires a study to be done on how different private insurance companies cover in-home telemedicine visits to determine what services would be suitable for Medicare to cover.

VanZee said the bill would be a solid step forward in expanding in-home telemedicine services to rural parts of the state and especially in areas lacking mental-health services.

“Legislation that removes barriers to access to care, as well as offering innovative ways to improve outcomes and reduce costs, is kind of covering the trifecta scenario for improving health care as a whole,” he said.

But even if federal legislators don’t pass the bill, it won’t stop telehealth from growing in Indiana. VanZee said telemedicine already has gained a strong foothold in the state that’s only going to get stronger.

He said the question now is what state and federal officials will do expedite the growth of telehealth services that could revolutionize how rural residents receive medical care.

“Indiana has made significant strides in the last five years in developing the right environment for telehealth and telemedicine,” VanZee said. “Regardless of whether the bill does or doesn’t pass, there still will be continued expansion of telemedicine.”

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