May 28, 2013

Deadly Physical Examination Requirements (PER)

When I wrote this blog back in July 2012, I thought I would never see it again. Then on March 12, it reappeared in two places, here, and here. This time I found an email for one of the authors and have a copy of the study. It is very interesting and with the articles and study, I will try to emphasize what the medical profession is doing to prevent telemedicine from happening.

First a little background about what started the rush to require the physician examination requirement (PER) before a prescription could be issued. Our internet pharmacies let their greed create much of this, but only those that did not follow the laws of the state in which they had facilities. There are three core models of the Internet pharmacy to consider. The first model is either part of or partnered with existing brick and mortar pharmacies. This means they adopted the procedures of traditional pharmacies including accepting prescriptions only from patients' physicians.

The second model of online pharmacies permitted patients to complete online health status questionnaires that were evaluated by physicians under contract with the pharmacy. After a favorable review, the prescription was written, filled, and shipped. The third model of online pharmacies is all located outside of the USA. They do not follow any rules other than to make the sale happen. The second and third model is what generated the rush to PER. I have no problem with this because of the problems these pharmacies have caused. The first model was not supposed to have been caught is this, but has when lawyers thought they could make some money.

The first PER restriction was implemented by the medical board of the District of Columbia in 1998. Between 1999 and 2006, 32 more states have put regulations in effect. The last state in 2006 to do this was Idaho. Only 17 states have not adopted PER.

Although PER was not specifically directed at telemedicine, the imposition of PER certainly had the potential to adversely affect key aspects of it. The practice of medicine at a distance, what we now call telemedicine, had its roots in 1960s. However, telemedicine expanded dramatically in the 1990s, as improvements in technology made it more useful and reliable. Telemedicine should generate significant savings in time costs rather than the monetary cost of telemedicine. This is the reason that the study calls for more studies to separately investigate the effect of telemedicine on those groups that experience the largest savings; people located in predominately rural areas and those living in areas of low physician densities.

From the intent to prevent access to a variety of non-beneficial drugs, the regulation has had the effect of raising the implicit cost of telemedicine. This created a trade-off of reducing access to medical care for some and giving some patients a higher quality of medical care. PER adoption has its greatest impact by elevating mortality in rural areas and areas of low physician density.

In 2008, the federal government implemented a nationwide PER, prompted by concerns over non-therapeutic access to drugs from foreign-based Internet pharmacies. Although some of the circumstances leading up to the federal legislation differ from those observed earlier at the state level, the methods we used may be of value in subsequent examination of the effects of this federal law. The findings are also relevant to policy discussions of the appropriate regulation of telemedicine. It seems that even if (as suggested by others) telemedicine offers somewhat lower quality care, its effect on access to care in rural and physician–deprived locales may be important in improving overall health outcomes. Finally, the results help illuminate some of the key margins to consider in the broader discussion over the regulation and provision of medical care, emphasizing the importance of identifying the relevant trade-offs between access and quality of care.

In my personal opinion, all PER laws need a careful review to eliminate the burden on telemedicine and allow telemedicine to proceed in rural and sparse physician areas. Yes, we still need laws to stop the two models of pharmacy sales that do not follow state or federal laws, but we do need to make allowance for legitimate telemedicine in largely rural areas where travel can be a real burden.

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