Final
The Current Regulatory Environment

HEALTH CARE TASK FORCE

Votes:
Action Taken:
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1:38 PM - The Current Regulatory Environment

Ned Calonge introduced himself as the President of the Colorado Board of Medical Examiners and Susan Miller introduced herself as the program director of the same, and stated that Rosemary McCool, Director of the Division of Registrations would also be speaking. The speakers distributed four handouts: 1) Colorado Senate Bill 98-036 (Attachment H); 2) Telemedicine Overview by State Chart (Attachment I); 3) a Report for the Ad Hoc Committee on Telemedicine (Attachment J); and 4) New Mexico Senate Bill 473 (Attachment K).

Mr. Calonge mentioned that most telemedicine is used in radiology where images such as x-rays and MRIs are sent to remote areas for reading, and pathology where the same is done for tissue slides. He stated that these areas of medicine are put into one broad category called store and forward where the information is stored in a machine and forwarded to the health care provider for analysis. Mr. Calonge explained how telemedicine allows a real time consultation through a television set and stated the ideal use of telemedicine is between a patient and doctor in a rural area and a specialist in an urban area. Mr. Calonge then went through and listed the many areas of specialty medicine that have worked well with telemedicine such as pediatric primary care, cardiology, rehabilitation, and psychiatry.

Mr. Calonge stated that as good as the technology is there is still the need for the in-patient, hands-on approach. He explained that telemedicine is very successful in its use for case management and self monitoring of chronic diseases in both urban and rural settings. He gave the example of a patient with diabetes who, through telemedicine, can do blood monitoring that goes into a computer that sends the information to the patient's remote provider. He explained how this type of monitoring is very successful but stressed the fact that emergency rooms are still needed in case the patient's condition worsens. Mr. Calonge then stated that while participating in a health sciences center study he was cautioned by a rural stakeholder to be careful about assuming the care of rural patients in a metro area because it takes that revenue out of the local setting and takes away the primary care from the local physicians because the care is going elsewhere.

Mr. Calonge discussed the barriers to telemedicine. He stated that reimbursement levels are the greatest barriers to telemedicine. He mentioned that the Centers for Medicare and Medicaid Services have severe restrictions for Medicare reimbursement and most private insurers do not cover telemedicine. Another barrier he discussed was malpractice liability, and how because of telemedicine, remote care is being judged at the same level as direct patient contact. He also stated there is some concern with the technology itself causing a loss of hands on care. Mr. Calonge added that another barrier to telemedicine is licensure, and the need to be licensed in the state where you provide care. Then Mr. Calonge addressed the problem of illegal prescribing and that no state he knows of has the resources to monitor and address the numerous violations of illegal internet prescribing.

Representative McCluskey commented that although it seemed as though telemedicine would take away money from rural area hospitals and doctors, it would also fit well in some rural areas where it is hard to find doctors. Mr. Calonge agreed and added that not all rural areas are exactly the same. Therefore, policy in telemedicine must be strategic and allow local health care providers to thrive while at the same time providing medical care services where there are none.




Representative Butcher asked where the areas not served with telemedicine are generally located. Mr. Calonge stated there are ways to get that information, but explained it is a complex issue. Mr. Calonge concluded.


1:52 PM

Susan Miller explained that she would be discussing the current status of telemedicine regulation both in Colorado and in the nation. Ms. Miller stated it is important to understand that the regulatory view of telemedicine means that the practice of medicine occurs where the patient is located. She explained that is important because it determines who has jurisdiction over the care provided. She gave the example that Kansas rules and regulations would cover a Colorado doctor giving care via telemedicine to a Kansas patient.

Ms. Miller referred to Senate Bill 98-036 (Attachment H), legislation that regulates telemedicine in Colorado. She explained that Senate Bill 98-036 requires physicians who practice medicine in Colorado by means of telemedicine to have a valid Colorado medical license to legally do so. She then noted a couple exceptions to that rule: 1) physician to physician consultations; and 2) pathology services.

Ms. Miller discussed the second handout (Attachment I) regarding the status of telemedicine by state. She stated that currently 38 states, including Colorado, require physicians to hold full medical licenses in that state to legally provide telemedicine services but some, like Colorado, have exceptions to that rule. She explained that nine of the states on the list have adopted the Federation of State Medical Board's Model Act that provides for a limited telemedicine license. She mentioned that one of the states that allows a limited telemedicine license is New Mexico which offers the license to physicians who only practice telemedicine. She stated that the national trend, however, is to require physicians who practice telemedicine to hold full medical licenses.

Ms. Miller pointed out recent legislation passed by New Mexico (and pending in New York and Texas) to create telehealth commissions and referred the committee to the handout of the legislation (Attachment K). She explained that the legislation creates the New Mexico Telehealth Commission and referred the committee to the first page where the purpose of the commission is laid out. She explained that because the commission is so new there is not a lot of information about it available.

Ms. Miller discussed two projects the Colorado Medical Board of Examiners is currently involved in. One is a meeting with the Four Corners Telehealth Consortium to find ways to advance license portability between the four corner states that will be held October 18, 2005, in Phoenix. The other is a federal demonstration pilot project to advance telehealth and license portability by establishing a central database.

Mr. Calonge responded to Representative Frangas' request for clarification on the concerns of the rural stakeholder mentioned earlier.


2:03 PM

Rosemary McCool, Director of the Division of Registrations at the Department of Regulatory Agencies, explained that she has the broad oversight of all the professional occupational licensing and that she would be discussing where Colorado is with the nursing compact. In 1998 the National Council of State Boards of Nursing implemented a process where states could enter into a compact that would allow nurses licensed in one of the 18 states in the compact to practice freely within those states. Ms. McCool stated that Colorado is not yet part of the compact, but the Department of Regulatory Agencies supports the compact.




Representative Butcher asked how the "bad actors" would be monitored through the compact so that they would not just move to another state to avoid discipline. Ms. McCool stated that she believes, now that they are 6 years into the program, the problems with bad actors have been fixed. Representative Butcher asked what impact the compact would have on the nursing shortage and restrictions that come along with it and if the compact would cause more nurses to leave Colorado. Ms. McCool stated that she had just attended a national conference and the council was very clear that this was not a model to fix the nursing shortage, but that it allows nurses to move freely from state to state.

Representative Todd asked if any of the 18 states involved in the compact are neighboring states. Ms. McCool stated that Arizona, New Mexico, Nebraska, and Utah are currently members of the compact. In response to a question posed by the committee, Ms. McCool stated some of the drawbacks of the compact. One drawback is that it may be hard to track bad acts of nurses from one state to another, and another is the revenue issues as to which state receives the licensing fees from the nurses. She gave the example that New Mexico will receive the revenue from a nurse who pays for a license in New Mexico but who practices in Colorado thus taking those fees away from Colorado's revenue.

In response to Representative Butcher's question about continuing education for licensed nurses, Ms. McCool stated that continuing education is not required for nurses in Colorado at this time, but it could be an issue in another state.


2:09 PM - Recess