The health care polity that is Texas

by on August 27, 2017 at 12:30 am in Law, Medicine | Permalink

The Texas Legislature just enacted landmark health care reforms by opening the state to telemedicine. This success shows that states have great power to improve health care without waiting on Washington. This is especially important as the Affordable Care Act (ACA, or “Obamacare”) grows more unstable and neither party in Congress seems capable of responding.

Telemedicine can improve health and lives—especially in a sprawling state with vast, thinly populated areas. As high-quality video conferencing and remote telemetry become more sophisticated and less expensive, telemedicine offers high-quality care without the need for face-to-face contact in many (not all) situations.

Since an episode of cardiac arrhythmia, I’ve carried a $99 device (AliveCor.com) that conducts clinical-quality electrocardiograms, analyzes them, and gives one-touch, low-cost access to professional help. My then-92-year-old mother’s life was probably saved by an iPad FaceTime conversation with her grandson (an M.D.), who sensed the onset of sepsis. Low-cost digital stethoscopes, blood pressure cuffs, and other devices can plug into smartphones or tablets, transmitting information directly to teledoctors.

…Senate Bill 1107 allows patients to receive prescriptions from doctors whom they meet for the first time via electronic means.

Here is more from Robert Graboyes.

1 Epictetus August 27, 2017 at 12:45 am

Very glad your mother was saved, and interesting to know about devices that yoi mention. That telemedicine is illegal im so many places is cruel and barbaric. A few years ago, by independent, unrelated chances, at diffetenf times withing the same year, my wife, my mother and I each very nearly died. Only chance saved each of us then, but telemedicine in all cases would almost certainly have avoided getting to so close to death in the first place. Most doctors and health managers I talk to however are dead against telemedicine in practice, so to speak. Boneheaded bureaucrats.

2 prior_test3 August 27, 2017 at 12:53 am

Telemedicine will undoubtedly be of great benefit during the next coastal hurricane, or following a string of tornadoes. Or it will actually reduce the number of local medical professionals able to actually respond at a time of peak demand.

But this is hilarious, considering that one party is actually in charge of both the legislature and executive – ‘unstable and neither party in Congress seems capable of responding’ The people in charge are the people in charge of responding.

‘Allows patients to receive prescriptions from doctors whom they meet for the first time via electronic means’ sounds more like a profit bonanza for the pharma industry than some major step forward in improving access to medication. The doctor gets their cut under either scheme, of course.

3 Larry Siegel August 28, 2017 at 4:16 am

Well, the coastal hurricane has arrived and it is a doozy. How many lives do you think might be saved by making it possible for injured or sick Houstonians to get a prescription over the phone while waiting for the waters to recede so they can drive their (flooded) cars to the doctor or hospital? 1000? 5000? Although the practice is subject to abuse, it sounds worth it to me.

4 BC August 27, 2017 at 1:11 am

If Texan doctors can prescribe medicines for patients they meet via electronic means, then does that mean even residents of other states can access telemedicine through Texan doctors? The doctor is located in Texas, so he or she presumably is regulated under Texas law. The patient, say a resident from non-Texas state X, connects to the doctor via internet, so how would that be different from the patient visiting Texas and receiving a prescription during the visit? If state X tries to regulate that activity, then wouldn’t that fall under interstate commerce, which is the purview of the federal government?

5 Borjigid August 27, 2017 at 8:40 am

Presumably you could get a prescription from a Texas doctor and fill it at a Texas pharmacy, even if you were from (say) Illinois. But your Illinois-based insurer would refuse to pay for it.

6 Zzz August 27, 2017 at 11:56 am

Only if they have a license to practice medicine in your state.

7 Andre August 27, 2017 at 2:55 am

I don’t understand these shots about waiting on Washington and the ACA becoming unstable. If McConnell and Ryan took lead on an amendment to allow greater access to telemedicine in the rural communities as an amendment to the ACA does anyone really think there would be some massive push back from the Democrats?

8 stuart August 27, 2017 at 8:49 am

….. our socialist Democrats strongly favor more government control over physicians & health care — NOT relaxation of government controls. Ultimately they want a single-payer system with all physicians effectively working for the Federal government.

9 Moo cow August 27, 2017 at 10:35 am

Democrats are certainly not united on that view. A very small minority of Democrats want the government to employ the doctors.

10 BC August 27, 2017 at 11:54 am

In your mind, what is the distinction between government employing the doctors vs. a single-payer system where taxpayers must purchase government “insurance” and that insurance regulates or negotiates prices? Premiums for insurance that one is mandated to purchase is no different from a tax. When doctors can get paid only by government insurance at government-set rates, then those doctors seem indistinguishable from government employees. Democrats don’t favor having their health care system *labeled* as socialized or government medicine. They do favor so heavily constraining the health care system through regulation and mandates that the only system that can satisfy the constraints in practice is indistinguishable from government medicine.

11 Harun August 27, 2017 at 12:40 pm

Are you sure the Democrats wouldn’t try to tie it to planned parenthood funding or protecting some other turf?

Remember, the GOP passed reform bills that did exactly what Obama himself had done via executive orders, and Obama vetoed them.

Don’t imagine that the Democrats are all reason and light. They are just as partisan as the GOP, if not more so.

12 Evan Harper August 27, 2017 at 4:38 pm

No-one who’s not an uninformed fanatic thinks that, but, well, this is Tyler’s comments section sooo

13 Strick August 27, 2017 at 5:39 am

Every technology gets abused. How long until the first prescription mill going telemedicine gets busted? I’d expect certain classes of prescriptions written via telemedicine to receive extra scrutiny from payers and law enforcement. And how many hours can a doctor bill for services rendered via telemedicine, especially when billed across multiple payers who don’t compare claim volumes?

14 Mohammad August 27, 2017 at 5:54 am

Texas ratifying DTC telemedicine is like announcing in 2017 that minorities finally have the right to access the internet! We’ve been doing telemedicine with our patience since medicine and the telephone simultaneously existed. I understand the concern of healthcare dollars leaving the State as most of the telehealth platforms are based in California. But telemedicine, even though it has many flaws and limitations, is an incredibly inexpensive way of including those who have no good/affordable access to medicine.
This is not a landmark case, it’s a sign of how backwards the Texas medical board is.

15 dearieme August 27, 2017 at 5:59 am

A friend of mine has a pacemaker/defib fitted. He also has a bedside device that reads the record and uses the mobile phone network to dump the data to the local hospital. He tells me that cardio technicians check that data monthly. I presume that there’s also some automatic method of sounding an alarm if the record is worrying.

Prescriptions: I can request repeat prescriptions from my GP over the internet. I can collect the medicine from my local pharmacy or, on request, they will deliver it to our front door.

My GP consultations can take place in three ways. (i) Much the commonest, I visit her. (ii) We speak on the phone. (iii) She visits me – rare but available. One of her predecessors on a home visit perhaps saved my life. It took me some time to realise that when Americans refer to a doctor’s visit they actually mean a patient’s visit.

Our traffic problem is so bad that her predecessor used to do her home visits by electric bike. It worked a treat.

16 mulp August 27, 2017 at 6:13 am

Insurance drives the patient contact model. Is Texas defining remote contact with a patient as legally direct patient contact under the terms for medical billing?

Many rural areas use telemedicine today, often as part of government health services.

Note, this requires going to clinics as the patient population do not have the network connectivity, much less equipment for more than a telephone conversation. But for that, many people get medical advise and prescriptions by phone, tho insurance seldom pays the doctor.

Note, Federal and State laws prohibit prescribing certain drugs by phone or fax, but electronic transmission might not be as restricted, but those are traced to a doctor more reliably than a signed prescription form.

17 John Goodman August 27, 2017 at 8:24 am

Actually, Texas is the last state in the nation to do this.
See my op ed in the Dallas Morning News.
https://www.dallasnews.com/opinion/commentary/2017/06/20/visit-doctor-virtuallyand-might-finally-changing

18 Moo cow August 27, 2017 at 10:39 am

Heh.

19 Jerry Plumlee August 27, 2017 at 2:36 pm

+1

20 Thor August 27, 2017 at 9:18 am

I am imagining Doctor Nick Riviera calling in from Mumbai.

On the other hand, we get some of our software diagnosed online. So why not our bodies?

21 steve August 27, 2017 at 9:37 am

John is correct. Texas is the last state in the nation to adopt some form of telemedicine, so not sure they deserve any special praise for this. Also, if you are in the field, it is not really clear that telemedicine is accomplishing as much as we hoped. No clear evidence it is lowering costs, and may actually increase total spending. It does not lessen the need for providers when an intervention is needed, and you still need some way to pay for the prescription once it is ordered.

That said, I still have high hopes for telemedicine with ICU care. However, in order to make it work financially the telemedicine docs need to be licensed in multiple states which is a huge barrier. It takes months to get that done for each individual doc. As chair of a department with some docs who to be involved in telemedicine I have to fill out dozens of forms, and the individual doc fills out many more (a huge time sink). One of my guys has spent over a year and is about to give up. Libertarian Tyler and his supporters here will probably oppose this but if we had a national licensing system this would work much better. (And for those who oppose licensing, as long as liability is an issue in the US, that is not going away.)

Steve

22 Bill August 27, 2017 at 9:57 am

Texas discovered America.

Sorry, this is typical Texas bragging unmoored by the facts, with some political, unrelated and incorrect digs as a complementary side dish in the article.

Arkansas, Colorado, Connecticut, Delaware, Idaho, Indiana, Maine, South Carolina, Virginia and West Virginia already allow telemedicine.

You mean that Texas didn’t discover America.

23 Vivian Darkbloom August 27, 2017 at 11:04 am

It appears to me that the objections against prior Texas law are overstated. Note that prior law prevented Texas physicians only from writing prescriptions for patients “whom they had never met”. I understand that “tele-medicine” per se was not previously barred in Texas. For example, I understand that a physician in Texas could consult with an existing patient (one he or she had previously seen in person) by telephone or internet and write a prescription for that existing patient without an in-person consultation. There’s a very big difference between barring “telemedicine” completely and the rather benign restrictions that heretofore existed in Texas.

On the other hand, it appears that the rules regarding opening a bank account and doing financial transactions via one’s bank are much more restrictive under “know your customer” rules than are rules regarding a physician prescribing drugs to a patient. It would probably be much easier for me to get an opiate prescription from a doctor I’ve never met in person than it is to open a bank account remotely or to transfer $10,000 of my own funds from my US account to one of my accounts in Europe.

Interesting how these rules are going in opposite directions…

24 rayward August 27, 2017 at 11:05 am

Prescribing a narcotic without first conducting a physical exam violates the physician’s oath; sure, she may not have liability to the patient as the result of this new law, but it’s an ethical and professional failing. I’ve worked with physicians in developing uses for telemedicine (in capnography), and there is tremendous potential for its use. But the potential is limited and must be used as part of a program of coordinated care among physicians with differing expertise, such as local physicians working with physicians in distant centers of excellence who can provide the specialized care not available locally. The idea that physicians in a remote location can provide quality care alone is a fraud.

25 hoonose August 27, 2017 at 12:19 pm

Summer of ’78 during my medical residency I went fishing into the far northern reaches of Saskatchewan. Cree Reservation area. They showed me their direct satellite/audio hook up to doctors in Ottawa. Benefits were enormous. If there was a trauma case, there was no reason the doc could not prescribe a narcotic for pain. That is doing what is in the best interest of the patient.

https://en.wikipedia.org/wiki/Churchill_River_(Hudson_Bay)

26 rayward August 27, 2017 at 3:25 pm

Of course, you confirmed my point: telemedicine offers tremendous potential in unusual situations, such as in remote areas. What you fail to see is the distinction between the unusual and the usual.

27 Careless August 27, 2017 at 6:18 pm

So you’re saying you were wrong when you said it violates their oath.

28 Careless August 27, 2017 at 6:18 pm

So you’re saying you were wrong when you said it violates their oath.

29 hoonose August 28, 2017 at 12:25 am

First do no harm always has to be weighed into any medical decision making process. Prescribing a narcotic may be indicated in the right situation without a direct hands on examination.

30 Slugger August 27, 2017 at 12:03 pm

British Columbia has had an official telemedicine program since 2008. Like Texas they face the issue of covering a very large area with travel issues in the winter that might even be worse than in Texas. They seem to be very pleased with their program. I know someone in Smithers who has lung cancer. She did have a face-to-face with the oncologist in Vancouver initially, but she and her nurse practitioner have been in regular contact with the center electronically for the past year which was especially useful this winter. She is responding well to treatment and feeling well more than 15 months after a diagnosis of stage four lung cancer.

31 Dave Tufte August 27, 2017 at 1:08 pm

Me too, Tyler.

I was on a long distance cellphone call with my 75-ish parents. My Mom handed my Dad the phone to go do something in the kitchen. After a few minutes, he started slipping into a diabetic coma. He was not responsive enough to call my mother, but I kept him intermittently conscious. I went and got a landline, called their landline, got my Mom, and she called the EMT’s. All was well within an hour.

32 Evan Harper August 27, 2017 at 4:40 pm

it would be nice if we could discuss this innovation without insane partisan lies about how obamacare is totes collapsing and it’s, uh, everyone’s fault I guess, certainly there’s no difference in the two parties’ commitment to making health care work or anything like that

33 Evan Harper August 27, 2017 at 4:41 pm

ohhhh….

> Robert Graboyes is a Senior Research Fellow and Health Care Scholar at the Mercatus Center at George Mason University

explains a lot

34 Careless August 27, 2017 at 6:19 pm

” insane partisan lies about how obamacare is totes collapsing”

lol

35 JWatts August 28, 2017 at 7:19 pm

Yep, it’s an insane partisan lie that major insurance companies keep leaving the Obamacare market after losing vast amounts of money.

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