Orthopedic Telemedicine’s Tortuous Journey to Mainstream Health

Orthopedic Telemedicine is having a pretty rough teenage period. Patients like getting medical care, devices and prescription drugs by phone. And major care providers increasingly like to deliver care, devices and drugs by phone.

It’s become one of the fastest growing corners of orthopedic medicine.

Unfortunately, sophisticated scam artists also like telemedicine.

Should you participate and if you do, what do you need to know to avoid other supplier’s mistakes?

Here are some answers.

The Rise of Telemedicine

The American Medical Association’s (AMA) website reports that a “national study of insurance claims filed for alternative settings of care found telehealth rocketed up 53% from 2016 to 2017.” On June 5, 2019, Beckers Hospital Review released a list of 12 hospitals/healthcare systems that began implementing new telehealth services in May:

1. Allina Health (Minneapolis) in conjunction with Hayward Area Memorial Hospital (Wisconsin)
2. AdventHealth Dade City (Florida)
3. The Medical University of South Carolina (Charleston)
4. Appalachian Regional Healthcare System (Kentucky)
5. Ochsner LSU Health Monroe (Louisiana)
6. Texas Tech University Health Sciences Center
7. Shriners Hospitals for Children (Chicago) partnering with Cameron Memorial Community Hospital (Indiana)
8. UPMC funded Infectious Disease Connect (Pittsburgh)
9. Baxter Regional Medical Center partnered with the University of Arkansas for Medical Sciences
10. Lee Health (Florida)
11. Medical University of South Carolina
12. Joseph Healthcare (Maine)

Telehealth can include review of medical imaging, video conference and consultations with healthcare team members in separate locations, among other services.

Telemedicine is absolutely for real.

But watch out.

FBI, HSS Inspector General Lowers the Boom

In April 2019, federal agents broke up an orthopedic telemedicine scam that cost the Medicare system $1.2 billion and resulted in charges against 24 people, including medical doctors who wrote fraudulent prescriptions. As a result, Medicaid pursued legal action against roughly 130 medical equipment companies. The Health and Human Services Office of Inspector General (HSS), the Federal Bureau of Investigation (FBI), the Internal Revenue Services, and 17 U.S. Attorney offices collaborated on uncovering the operation.

In this scheme, orthopedic braces were marketed to seniors via telemarketers and through media advertising. Seniors who expressed interest in receiving a brace were transferred to international call centers where their Medicaid coverage was verified. They were then transferred to telemedicine companies for medical consult. Unneeded orthopedic braces were prescribed, garnering $500 to $900 in payout profits per script from Medicare. These profits were laundered and used to purchase luxury cars, homes and yachts, domestically and internationally. See OTW’s full coverage of the scam here: Feds Bust $1.2 Billion Medicare Orthopedic Brace Scam.

Unfortunately, these types of scams are becoming commonplace. Other telehealth companies, such as Nurx, a California-based company that sells prescription medications through the internet, have also recently been accused of violating state and federal laws related to medication prescription.

These events raise questions into the nature and ethics of telemedicine as well as the healthcare system in general.

Why Is Telemedicine Increasingly Popular?

Benefits of telehealth care include ease of scheduling for both provider and patient. Providers also benefit from their ability to schedule a higher volume of billable services within a given time.

Telemedicine delivers healthcare to remote or underserved communities, mitigates travel expenses and work scheduling stressors, reduces emergency department trips and wait times, and increases access to health care for at-risk populations.

In terms of orthopedic surgical care, postoperative consults and image review may be practical approaches for both overscheduled providers and recovering or temporarily handicapped patients. Additionally, avatars are beginning to be used in physical therapy and post-operative recovery.

Virtual Orthopedic Care Is Comparable

Virtual orthopedic care has been shown to be comparable to traditional health care. A 2016 study published in the Journal of Medical Internet Research by Astrid Buvik, M.D., of the Orthopaedic Surgery Department at University Hospital of North Norway, and colleagues compared 400 patient experiences of standard and virtual orthopedic care, utilizing assessment of quality of care by experienced orthopedic doctors and surgeons.

The study found that “In the ancillary analyses, there was no significant difference between the two groups.” The study authors concluded that the study “supports the argument that it is safe to offer video-assisted consultations for selected orthopaedic patients,” and that more research is needed to clarify to what extent this care is effective in various applications.

Emerging Types of Telemedicine

According to a May 2019 American Medical Association article titled, “Next Step in Telehealth Could Be Surgery Rehab Led by an Avatar,” the use of “telerehabilitation following total hip and knee arthroplasty lowers rehabilitation costs by an estimated $1,000 per patient and boosts patient adherence with exercises as they recover.”

The AMA article examined a study that was presented at the American Academy of Orthopaedic Surgeons’ annual meeting, titled “Tele-Rehabilitation for Total Hip and Knee Arthroplasty Patients: No Increase in Readmissions.” Orthopedic surgeon Mary I. O’Connor, M.D., Director of the Center for Musculoskeletal Care at Yale School of Medicine and Yale-New Haven Health who co-authored the study explained how tele-rehabilitation could benefit patients.

She said, “A surgeon can do a fabulous operation, but if the patient doesn’t do exercises, the outcome is often compromised. Now you are giving patients a tool to do exercises at home that engages them and provides feedback on how accurately and how often they are performing the exercises.”

Guidelines and Ethical Rules

What standards are telehealth professionals held to?

The Federation of State Medical Board (FSMB) guidelines on telehealth states that “Treatment and consultation recommendations made in an online setting, including issuing a prescription via electronic means, will be held to the same standards of appropriate practice as those in traditional (encounter in person) settings.”

AMA Code of Ethics similarly states that “Physicians who provide clinical services through telehealth/telemedicine must uphold the standards of professionalism expected in in-person interactions, follow appropriate ethical guidelines of relevant specialty societies and adhere to applicable law governing the practice of telemedicine.”

However, the FSMB guidelines detailing protocol on medical prescribing leave the details to the discretion of the provider. “Prescribing medications, in-person or via telemedicine, is at the professional discretion of the physician. The indication, appropriateness, and safety considerations for each telemedicine visit prescription must be evaluated by the physician in accordance with current standards of practice and consequently carry the same professional accountability as prescriptions delivered during an encounter in person. However, where such measures are upheld, and the appropriate clinical consideration is carried out and documented, physicians may exercise their judgment and prescribe medications as part of telemedicine encounters.”

Leaving details to the discretion of the telemedicine provider raises ethical concerns in the face of the national opioid epidemic. In January 2019, CNN reported that the National Safety Council found that for the first time the odds of death via opioid overdose are statistically higher than those of dying from a car accident. Internet sites offering fraudulent medical care including opioid scripts are also becoming a problem.

Legislation and Government Action

In September 2018, the Senate passed the Opioid Crisis Act of 2018, which outlined the importance of telemedicine supervision in the epidemic and opened the door for a slew of bills seeking regulation of policies for telemedicine companies including the e-Treat Act, Medicaid Substance Treatment Via Telehealth Act and the Telehealth for Children’s Access to Services and Treatment Act. The Senate’s Opioid Crisis Act must now be reconciled with the House-passed opioid package.

On April 2, 2019, the United States Food and Drug Administration (FDA) announced that it issued two warning letters to websites that illegally market opioids online. The agency reports issuing 25 such letters to 450 websites that offer illegal opioid sales since September 2017. The FDA cites illegal opioid internet sales as a current “major public health concern.” The agency also hosted a second summit meeting on this issue this past April.

What’s Next

For all the reasons enumerated above, telemedicine should continue to grow rapidly. It is no stretch of the imagination to expect that it will enter the mainstream of orthopedic or spine care.

But the ethical issues around confidentiality, the nature of the patient-provider relationship as translated through the phone lines or the Cloud and issues of safety around potentially harmful or addictive medications or orthopedic equipment warrant continued exploration.

And, no doubt, there will be further development of legal guidelines.