American Journal of Law & Medicine

The virtual health economy: telemedicine and the supply of primary care physicians in rural America.

I. INTRODUCTION

For years, people living in rural areas have struggled unsuccessfully to attract and retain primary care physicians to supply basic medical care to their residents.(1) Rural areas continue to suffer from chronic shortages of physicians and mid-level practitioners,(2) as well as high rates of hospital closures and increased levels of uninsurance and underinsurance, reducing both the physical and financial health of these communities.(3) Physical and economic barriers unique to rural areas block the adequate delivery of health care and contribute to this shortage of health care personnel.(4)

Although Congress has made some progress in identifying where health care shortages occur, it has not adequately identified the source of the shortages, and thus, it has not been able to find adequate solutions to rural health care ills.(5) Past legislative action has involved identifying shortage areas and then providing financial incentives to attract physicians and increase the financial health of hospitals by subsidizing the difference between rural America's ability to pay and what physicians are willing to accept.(6) Congress' actions have implied that they believe the cause of the shortages is that rural buying power is insufficient to meet the price demands of physicians and attract them to rural America. While the supply of physicians in rural areas is no longer decreasing, it has not met expectations or need,(7) and the financial health of rural hospitals has continued to decline at alarming rates.(8) Despite this continued deterioration, until recently, Congress has retained the subsidy approach and the implied definition of the problem as insufficient rural buying power. However, the limited success of the subsidy approach demonstrates that limited buying power does not tell the whole story. Other factors may also affect the market for primary care physicians in important ways. This problem needs an approach that completely addresses the characteristics that keep rural areas from receiving their basic health care needs. This Note proposes that the solution to addressing these other factors and supplying basic medical needs is telemedicine.(9)

Telemedicine has the potential to act as the conduit for delivery of medical services from urban areas, where there is a surplus of physicians, to rural areas, where there is a shortage.(10) Telemedicine systems transmit patient data in the form of images and sounds from one location to another and allow a physician at one location to view and hear patient data from miles away.(11) Telemedicine can range in sophistication from a fax machine to two-way interactive video and audio systems that allow transmission of a patient's image, as well as diagnostic data, including lab results, CT scan images and even the sound of a patient's heartbeat.(12) Because telemedicine can bring a doctor and patient together over video link, it allows physicians to provide consultations, supervise treatment, or conduct examinations remotely, thus instantly bridging the gap between the demand for care in rural settings and the larger supply of physicians in urban areas.(13)

In order to conclusively determine whether telemedicine is the missing piece in the primary care shortage puzzle, this Note more thoroughly defines the problem itself.(14) Part II presents the problem by reviewing the factual background of telemedicine and the rural health care crisis. Part III examines Congress' failure to increase the supply of physicians by analyzing Congress' rural buying power definition of the problem and the subsidy approach solution. In particular, it is important to determine whether there are other causes of the primary care shortage and whether the subsidy approach addresses possible causes other than limited buying power. Part IV explores the arguments for and against increased congressional utilization of telemedicine to address rural health care shortages. The value of telemedicine must be compared both to the shortcomings of congressional response and to the problem of rural health care delivery in general. By doing this, it is possible to determine whether telemedicine is an appropriate supplement to current congressional action. Finally, Part V concludes that telemedicine can effectively overcome some rural health care barriers that Congress is not currently addressing and should be used in conjunction with current congressional efforts.

II. FACTUAL BACKGROUND

A. WHAT IS TELEMEDICINE?

The term telemedicine generally describes the use of telecommunications to enhance the delivery of medical care by allowing a consulting physician at one location to observe a patient or data concerning the patient at another location.(15) Telemedicine systems range in complexity from transmitting diagnostic data by fax and consulting with a specialist by telephone(16) to two-way audio and video links that allow a physician to remotely diagnose, treat or consult about a patient from miles away.(17) Necessarily, the medium used determines the type of medical care that can be effectively delivered.

Telemedicine systems can be separated into three basic categories by levels of complexity. The least complex system is a one-way visual system supplemented by telephone consultation.(18) This system can transmit still images one-way from a local physician to a consulting physician, with the consulting physician following up by telephone.(19) A common example of this type of system is a fax machine. In the Texas Tech Mednet Project, a federally funded demonstration project, physicians faxed fetal monitoring information to the Texas Tech University Health Sciences Center and were able to successfully manage ninety percent of the revealed abnormalities by telephone consultation.(20) This system has the virtue of both simplicity and efficiency. Without telemedicine, this sort of consultation could only be accomplished by sending the data by messenger or by mail. However, the types of care that can be delivered effectively with this system are limited to diagnosis of data easily reduced to paper.

Despite the limited nature of this type of system, it demonstrates some of the potential advantages of telemedicine. Consultation with this type of telemedicine system means a faster, better informed, and more confident diagnosis for the local physician than was possible by mail, messenger or non-consultation. The ability to confer with another physician may combat the feeling of professional isolation experienced by physicians for whom face to face consultations are not usually possible due to lack of nearby specialists.(21) The local physician may also learn from the consultation through experience in addressing the condition presented in a particular case.(22)

The more sophisticated telemedicine systems are potentially more useful. The next level of sophistication is a one-way visual and a one-way audio capability. Examples of this type of system are educational systems which originate in urban hospitals or major teaching hospitals and transmit Continuing Medical Education (CME) programs through video and audio.(23) This type of system demonstrates another potential benefit of telemedicine. Telemedicine could fill an educational need for rural physicians who cannot conveniently attend programs in urban areas by providing access to developing medical knowledge.(24) Therefore, as with telemedicine in general, this type of system has the potential to reduce the sense of isolation rural physicians often feel by keeping them up-to-date on the current state of medicine.(25) Additionally, this educational function should result in better patient care as the local physician will be familiar with the latest medical advances.

The most sophisticated telemedicine systems currently in use most closely simulate full remote examination of patients by a consulting physician.(26) These interactive systems are based on teleconferencing systems. They transmit two-way video and audio and can be configured to transmit the signals for electronic diagnostic equipment such as electronic stethoscopes, otoscopes, endoscopes, microscopes, electro-and echo-cardiograms and sonograms among others.(27) The Medical College of Georgia (MCG) project is one of the most sophisticated of the federally funded demonstration projects. Their system includes an interactive television system, zoom cameras for dermatological exams, electronic stethoscopes and simultaneous transmission of digitalized x-rays and laboratory results.(28) In the MCG project, a rural physician examines a patient with a small camera attached to the examination instruments.(29) This gives the consulting physician, 150 miles away, as clear a view of the patient as the examining physician.(30) This two-way interactive system with color video gives the consulting physician a direct sense of the examination over the telemedicine link.(31) The only missing element of the examination is touch, and even that may not be impossible.(32) The MCG telemedicine system offers all the advantages of telemedicine. It produces instantaneous consultation while reducing the distance from miles to inches, thus, eliminating the need for most patients to travel.(33) As a result, these patients will no longer have to miss work or spend money on travel to urban hospitals. At the same time, these patients pay their fees to rural area providers, contributing to the rural economy.(34) Additionally, the immediacy of working with colleagues interactively over the telemedicine link alleviates the rural doctor's sense of isolation.(35) Finally, the system can easily accommodate educational transmissions designed to keep a rural physician current with the latest medical advances.(36)

The rudiments of telemedicine were in use thirty-five years ago. Massachusetts General Hospital transmitted fixed-camera video for the hospital's airport clinic to the hospital, but the equipment was expensive and so unwiedly that two flatbed trucks were required to move it.(37) This program led to fifteen federally funded telemedicine programs, but these programs each faded away as equipment was not updated or replaced because of expense.(38)

The resurgence of telemedicine has become possible only because of recent developments in technology. As a result, the new systems are smaller, less expensive, and are of increased quality.(39) The new interactive video system has two components: the equipment set and the transmission set.(40) The most important part of the equipment set is the coder-decoder (codec).(41) The codec converts the analog signal produced by the video and audio equipment to a digital signal that can be easily transmitted and then converts the signal back again at the other location so it can be received and broadcast. …

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