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Telemedicine services cut back in Cochise and 96 other U.S. counties







Medicare will no longer cover telemedicine in Cochise County and 96 other U.S. counties because they are now considered urban areas, instead of rural ones.

Because of the realignment of standard metropolitan statistical areas, about 1 million Medicare beneficiaries located in rural areas across the country will be affected, many who have been receiving healthcare with the help of telemedicine, said Gary Capistrant, public policy director for the American Telemedicine Association based in Washington, D.C.

“When people have made investments in equipment (and) patients have developed patterns of use with a particular provider…whether you’re urban or rural shouldn’t matter,’’ Capistrant said.

The cutbacks come at a time when the use of telemedicine is becoming more common across the nation for services ranging from the transmission of x-rays and CT scans to face-to-face consultations with physicians.

On April 5, Gov. Jan Brewer signed SB 1353, sponsored by Sen. Gail Griffin, R-Sierra Vista, which requires private insurers to reimburse for certain telemedicine services.  Among other things, the bill creates geographical boundaries to where telemedicine services are covered.

The reduction in service in Cochise County means patients who have had Medicare cover their telemedicine services will now have to pay for those services themselves.

And if they cannot afford to pay,  the clinics in the affected counties and the specialists connected with them will be working for free. That eventually could lead to the breakup of already established telemedicine networks, forcing rural patients to travel further to obtain care, even in an emergency situation.

The change caught Jim Dickson, CEO of the Copper Queen Community Hospital in Bisbee, by surprise. The  hospital, located in Cochise County, has offered telemedicine consultations with specialists in trauma, neurology, and cardiology for years, Dickson said. And about 40 percent of the telemedicine consultations at the Copper Queen are for patients on Medicare, Dickson added. “This will pull the biggest payer out of the scenario.”

And even with the Affordable Care Act coming into full effect in 2014, Congress will need to change the law, said Capistrant, if these counties are going to be covered.

“This isn’t something that the Centers for Medicare & Medicaid Services can do on their own, or President Obama could do on his own.”

Statistical Quirk

        The change came about because of the 2010 census and the way in which a county is defined as rural or metropolitan.

“Medicare has multiple definitions of rural and we’re stuck with one of the most restrictive,” Capistrant said. “Even the Grand Canyon is in a metropolitan area.”

Once a city within a county reaches a certain population level, the whole county becomes metropolitan. It is a very crude way to determine when and where telemedicine services will be covered, Capistrant said.

“We got bumped out because of Sierra Vista,” Dickson said. Of the 130,000 people living in Cochise County, about 50,000 now live in Sierra Vista. That has caused the entire county to be defined as metropolitan, Dickson said.

The other 80,000, however, are spread out around 6,000 square miles – the size of Rhode Island and Connecticut put together, Dickson added.

For states back East where counties are much smaller it may make sense, Dickson said. “When you got counties the size of states, then it gets to be a little bit crazy.”

There is no one agency or branch of government this is responsible for the recent decision, Capistrant said.

First the Office of Management and Budget identifies which counties are rural and which are metropolitan. “Then the Medicare people look at it and say, ‘Oh OK you’re no longer in a rural area,’ and so that’s how you get these crudities,” he said.

When asked for comment, the Centers for Medicare & Medicaid Services, which administers Medicare payments for healthcare providers and Medicare recipients, indicated it did not have any information available on the changes.

In addition to the equipment to allow video conferencing with a specialist, the Copper Queen Hospital has needed to increase its nursing staff and invest in stocks of expensive drugs that a telemedicine specialist would require to treat a patient, Dickson said.

Those investments, however, have greatly reduced unnecessary medical expenses, Dickson said.  In the area of cardiology alone, it has saved Medicare millions of dollars by not transporting so many people to downtown Tucson, Dickson said. The cost of a helicopter transport alone is about $25,000, Dickson added.

Pioneering work

Arizona was a pioneer in telemedicine. The first program, the Arizona Telemedicine Program at the University of Arizona, was founded in 1995 by former state Senator Bob Burns, currently a commissioner on the Arizona Corporation Commission, and Dr. Ronald Weinstein at the University of Arizona, an international expert on telemedicine.

Weinstein noted that now there are a number of other telemedicine programs in Arizona.  They range from the Banner Healthcare eICU program, where Intensive care specialists based at Banner Desert Medical Center in Mesa, Ariz. serve patients in Colorado, to the Mayo Clinic’s stroke telemedicine program that connects nine rural areas in Arizona with stroke specialists at Mayo in Phoenix.

The reclassification of rural counties to urban ones is grossly unfair, said Weinstein. He adds, however, that “the differentiation between urban and rural will disappear with time and that will be driven in part by the Affordable Care Act which is encouraging greater efficiency in healthcare and one of those efficiencies comes about by using telemedicine.”

Arizona Legislature

SB 1353 is designed to will expand the use of telemedicine throughout rural counties in Arizona as more doctors are able to get paid for providing telemedicine services, said Mike Keeling, an attorney and technology specialist who has advised the Legislature on the bill.

Keeling added that the reason language limiting telemedicine to rural areas was included in the bill was because private insurance companies were concerned about abuse.

“They are risk managing from their perspective,” Keeling said

It is cheaper and quicker for providers such as hospitals, to offer telemedicine servicers to patients, added Keeling. And when 30 million or more people, who must be covered by 2014 because of the Affordable Care Act, are factored in, telemedicine is thought to be one of those ways to improve the efficiency of medical providers and lower costs to both public and private insurers, Keeling said.

Copper Queen CEO Jim Dickson said those efficiencies are too important to get rid of even if Medicare won’t cover telemedicine services at his three locations in Cochise County.

“I am not going to get rid of these programs. They’re too efficacious. They provide care that you normally wouldn’t find in a rural area, and quite frankly, every Arizonan has a right to,” Dickson said.

“We’ll have to subsidize it at worse.”

­­­Arizona Medicare recipients by county as July 1, 2010

Apache                 9,073

Cochise                24,902

Coconino             17,793

Gila                        13,468

Graham                4,856

Greenlee             1,133

La Paz                    4,621

Maricopa             486,288

Mohave               47,586

Navajo                 16,872

Pima                      164,754

Pinal                      42,595

Santa Cruz           7,094

Yavapai                 52,382

Yuma                     26,197


Total                      919,910

Source: Centers for Medicare & Medicaid Services enrollment reports

97 Counties to Lose Medicare Coverage of Telemedicine

  • Alabama: Pickens County
  • Arizona: Cochise County
  • Arkansas: Little River County
  • Connecticut: Windham County
  • Delaware: Sussex County
  • Florida: Citrus County, Gulf County, Highlands County, Sumter County, Walton County
  • Georgia: Lincoln County, Morgan County, Peach County, Pulaski County
  • Hawaii: Kalawao County, Maui County
  • Idaho: Butte County
  • Illinois: De Witt County, Jackson County, Williamson County
  • Indiana: Scott County
  • Iowa: Plymouth County
  • Kansas: Kingman County
  • Kentucky: Allen County, Butler County
  • Louisiana: Iberia Parish, St. James Parish, Tangipahoa Parish, Vermilion Parish, Webster Parish
  • Maryland: St. Mary’s County, Worcester County
  • Michigan: Midland County, Montcalm County
  • Minnesota: Fillmore County, Le Sueur County, Mille Lacs County, Sibley County
  • Mississippi: Benton County, Yazoo County
  • Montana: Golden Valley County
  • Nebraska: Hall County, Hamilton County, Howard County, Merrick County
  • New York: Jefferson County, Yates County
  • North Carolina: Craven County, Davidson County, Gates County, Iredell County, Jones County, Lincoln County, Pamlico County, Rowan County


Source: American Telemedicine Association

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