Issues surrounding TeleHomeCare

TeleHomeCare has encountered several barriers in recent years, some of which include the following.

Cost & Reimbursement Issues

Senior holding moneyThe cost of equipment has been a primary barrier to full implementation and acceptance of TeleHomeCare. Traditionally, equipment costs have been expensive. However, further research has lowered those costs. Today, TeleHomeCare equipment can range from from 33 cents, the cost of an automated telephone call, to upwards of $25,000, for a full-fledged workstation that typically is found in hospitals. In Hays, Kansas, "the cost of setting up a standard home health telemedicine equipment in a patient's home is $800 to $900, or about the cost of an oxygen tank. The standard equipment includes a camera, a 13-inch color television equipped with a phone, an automatic blood pressure monitor and a tympanic thermometer." Vendors currently are working to reduce the cost of TeleHomeCare equipment. Despite equipment costs, experts say TeleHomeCare ultimately "is going to result in savings. . . . Overall, estimates indicate the savings could add up to about $10 billion a year in the United States," says Director of Telemedicine at the Medical College of Georgia in Augusta, Dr. Max Stachura. Patients also will save, as a pilot study in Georgia showed. "Sixteen families with special needs children found that using a home telemedicine system saved the group $28,000 in travel expenses and $38,000 in out-of-pocket costs over 9 months."

In his article, "Telemedicine: Capabilities, Growth Projections and Attending Issues Surrounding its Use," Dr. Jay Sanders reveals that medical consultations over the telephone traditionally have not been reimbursed. "It was generally assumed that clinical information, advice, or service provided over the telephone was not of sufficient scope to justify reimbursement, especially in view of the fact that telephone consultations rarely occur as a full substitute for a doctor visit, and no additional cost is incurred in having a telephone service. Typically, patients call for advice leading to a visit or subsequent to a visit."

For this reason, The Health Care Financing Administration (HCFA) has repeatedly denied Medicare reimbursement of TeleHomeCare, adding that TeleHomeCare has not been proven to be cost-effective. "It is a critical impediment," some experts say, "At least 50% of most US home care agencies' revenues are dependent on funds from Medicare." A recent article in Modern Healthcare reveals that, in 1997, "more than 1,000 home health agencies were forced to close . . . because of financial pressures."

There has been some improvement, however, in specific cases of reimbursement. The Balanced Budget Act of 1997, for example, has promoted telemedicine reimbursement in specific cases. Medicare reimbursements are allowed for specific, rural locations which the BBA has deemed as "healthcare professional shortage areas, or HPSAs." Under this stipulation, Medicare patients can stay in their hometowns to receive health care services via telmedicine. The BBA, however, does not provide reimbursement for home health services. Some health care experts maintain this refusal by the HCFA is the most noted obstacle to TeleHomeCare. This decision also has had profound impacts on the decisions of several commercial insurers; they too have followed the HCFA's lead.

In October 2000, a new means of paying for home care went into effect. Under this Prospective Payment System, or PPS, "payment for services will be dependent on providers' demonstrating and documenting their patients' maintained or improved health outcomes. If providers choose to use telemedicine during these 'episodes,' they may. 'Whatever works,' may be the attitude that's adopted before long, under PPS." The main characteristic of this new PPS system is that it apportions payment per episode of care (60 day periods), instead of payment for each visit. More needs can be addressed under the new PPS. And providers can better demonstrate their patients' improvements.

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Technology Issues

TechnologySeveral TeleHomeCare projects have found that patients have concerns about the technology. Patients have expressed concerns about the amount of electricity the equipment requires, the amount of space the equipment takes, and the "jerkiness" of video pictures. However, pilot project results also show that most patients respond to TeleHomeCare equipment positively, as long as they practice and receive continued encouragement from home health care providers.

A United Kingdom TeleHomeCare monitoring system project found that the system produced a high number of false alerts. Sensors placed around the house would detect abnormalities in patients' behaviors and would alert the home health care provider, who would in turn attempt to contact the patient to verify an unusual or potentially dangerous situation. The sensors in this UK project recorded 61 total alerts, 46 of which were false.

Another technological concern surrounding TeleHomeCare is the lack of an "open architecture." TeleHomeCare experts suggest the technology should have replaceable parts that can be upgraded as necessary, without providers and patients having to pay for a complete additional system. "This would permit occasional single component rather than total system replacement as indicated by new developments," Dr. Jay Sanders explains. The systems ideally should be interoperable, with different manufacturers sharing a national - or even international - standard, that ultimately would enable "revision, expansion, and substitution at competitive prices."

Overall, technical issues surrounding TeleHomeCare involve simplicity of operation and management, availability, reliability, and affordability. These technical barriers, experts say, appear to be the easiest barriers to overcome.

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Physician/Patient Resistance

Doctor and NurseStudies show some home health care providers have experienced difficulties in having their staff accept a new method of providing care. Dr. Guy Harris notes several players in the health care industry may resist accepting TeleHomeCare. The general practitioner (GP) may resist. Harris says, "If GP patients are lost to the hospital system, the GP's budget decreases. When 'expensive' patients are returned to primary care by early discharge, GP workload increases but income does not go up accordingly. Telecare woud facilitate the process of early discharge. Thus, to the GP, telecare could be a trap." The public hospital also could resist because it lacks the infrastructure and investment capital. The private hospital, on the other hand, has "the funds to invest in telecare and the incentive to use staff in the most economical manner."

Another obstacle is, what Medical Research Librarian Audrey Kinsella calls, "lower-tech individuals." People who are not accustomed to using a lot of technology, she says, can feel overwhelmed when a TeleHomeCare system is set up - or even considered. Some home health nurses say the challenge is to have TeleHomeCare adequately recreate the face-to-face experiences patients are accustomed to. A key to overcoming this barrier is for home health care providers to give meticulous attention to the needs of patients and to match the patient's needs with a specific TeleHomeCare tool.

A TeleHomeCare project in the United Kingdom revealed a number of concerns from patients. Lack of privacy was a worry. Patients said the home monitoring systems via sensors placed throughout the home gave them the feeling they were being watched. In their article "The Potential Impact of Home Telecare on Clinical Practice," Celler, Lovell, and Chan emphasize, "Individuls are entitled to assurance that personal information will not be subject to unauthorised access, and will be used only for the purposes it has been collected for. This requires procedures and processes to ensure that personal data can only be accessed by those authorised to do so."

Although privacy concerns were mentioned by several UK participants, they were not major concerns of project participants. A main concern for patients in the UK project was cost. Most patients said the TeleHomeCare monitoring systems were too expensive. Others saw the system "as a way of making money and cutting costs." The worry that the TeleHomeCare system would "reduce the human component in health and social care services" also arose as a major concern for patients in this TeleHomeCare project.

An article in the Journal of Telemedicine and Telecare revealed "the success of telemedicine applications (especially those for home care) does not depend only on their costeffectiveness but also on how well they serve the needs and address the concerns of patients. Therefore, investigating patients' impressions with accuracy and precision assists in the design and implementation of telemedicine systems that can improve the quality of care."

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By Daphne Landers

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