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Telemedicine set to expand in Texas

Coming to a video screen near you, thanks to a bill signed in May by Greg Abbott.

“This is a huge step forward, a real positive for Texas,” said Dr. Nancy Dickey, executive director of the Rural and Community Health Institute at Texas A&M University. She recently co-authored a report about the health crisis facing rural Texans amid hospital closings and other barriers to access.

Texas was one of the last holdouts in the rapidly evolving world of virtual medicine by requiring an in-person visit between doctor and patient in most cases before allowing diagnosis.

That requirement was at the heart of a bitter, six-year legal battle between the Texas Medical Board, which cited concerns of insufficient patient care, and Teladoc, a national leader in telemedicine.

Teladoc, headquartered in Lewisville, has more than 20 million customers nationwide, including 3 million in Texas. Previously in Texas the company used phones and high-resolution photos for diagnoses, as did other telemedicine companies in the state.

Teladoc has spent about $13 million in legal fees alone in the fight. The new state law presumably renders the fight moot.

The Texas Medical Board, made up of 19 regulators, declined to comment directly on the new law.

“The litigation, although abated, is still pending,” a spokesman said in an emailed statement.

“The need in Texas carried the day,” said Jason Gorevic, CEO of Teladoc. “This paves the way to expand.”

Or at least catch up with the rest of the country.

Texas currently dwells near the bottom of the nation in per-capita access to a physician, ranking usually between 46th and 48th, Dickey said.

In fact, 158 of Texas’ 254 counties do not have a single surgeon. In 185 counties, representing more than 3 million people, there is not a single psychiatrist. Eighty counties have five or less physicians.

While the traditional picture of telemedicine is one of linking a doctor to a patient in some isolated dot on the map, Dickey said it is equally useful for those in small towns who might be 30- to 45-minute drive from a specialist in a larger city.

Those patients, often older and poorer, may not have the time or energy to make a drive on rural roads, said Dickey.

“It is a way to take very specialized medical skills out to towns of 10,000 to 20,000 people,” she said.

See here and here for more on the lawsuit, and here for more on the bill that was signed that basically removed the barriers to telemedicine in Texas. I had been wondering about the status of the litigation since the compromise bill was announced. A little Googling yielded some more specific information than what is in this story.

Teladoc, which is based in Dallas, began operating in the state in 2005. But around 2010 the Texas Medical Board began restricting the practice of telemedicine, especially telemedicine by video, through a prescribing rule revision that required physicians to establish their patient relationship with an in-person visit.

This is where there are two different versions of the story. Teladoc and MDLive, which have operated continuously in Texas with their phone-only services, maintain that medical board rules have always permitted phone calls, even when they restricted the use of video telemedicine. The Medical Board, conversely, has maintained that this is essentially a loophole created by a drafting error and that the intent of the rule is clear: to forbid all telemedicine without an establishing in-person visit.

When Teladoc continued to use telemedicine by phone, the Texas Medical Board sent them a public letter telling asking them to stop, then issued an emergency rule clearing up any ambiguity between phone and video visits. Teladoc sued over the rule, saying that the interpretation of the law in the letter constituted a rule in and of itelf and that the making of that rule didn’t follow the proper procedures for rulemaking.

To make a long story short, that lawsuit beget a much bigger lawsuit in April 2015, one which might have gone all the way up to the Supreme Court. Teladoc sued the medical board under antitrust laws, saying that as a group of practicing physicians with a financial interest in the restriction of telemedicine, the medical board couldn’t pass rules designed to muscle out its competition.

“Unfortunately we had to go to bat for our clients’ right to avail themselves of our services,” Gorevic said. “But it was worth the effort, and we see that as our responsibility as a leader in the space. We never ceased operating in the state and in fact we were reluctant to go to court, but ultimately the reason we went to court was to protect our right to continue to operate and the right of our clients to operate our services. … We stepped up and took a stand and we didn’t see any of our competitors doing the same thing.”

That lawsuit dragged on for two years with a number of twists and turns and cost Teladoc $7 million in a single quarter, according to a public earnings call. Indications were looking positive for the company (the FTC, the federal government’s primary antitrust actor, even filed a friend-of-the-court brief on Teladoc’s behalf), but ultimately the two sides realized they would rather reach a compromise than take the case any further up the ladder. Last fall they requested a stay in the case and a settlement seemed likely to follow.

Gorevic confirmed to MobiHealthNews that if Abbott signs the bill, it will essentially end the long legal battle.

“We expect that the legislation, if signed by the governor, will end the lawsuit,” he said. “It will obviate the need for the lawsuit.”

That story was published May 26, and an update to it at the top confirms the bill’s signing. I didn’t find anything more recent than this in Google News, so I presume the details of the settlement are still being worked out. As I said before, telemedicine isn’t a panacea – it will be of limited use to people who still don’t have insurance, for example – but it’s a good option to have. We’ll see how much it takes root in the state.

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