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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