The Telehealth Advancement Act of 2011 updates California telehealth law and removes policy barriers to telehealth use.
AB 415, which became law Jan. 1, 2012, was authored by Assemblyman Dan Logue, R-Lake Wildwood, and sponsored by the California State Rural Health Association. It updates legal definitions of telehealth, streamlines medical approval processes for the delivery of services via telehealth, and broadens the types of services that can be provided via telehealth.
AB 415 drew from CCHP’s Telehealth Model Statute Report, which recommended modernizing state telemedicine and workforce laws, to encourage more robust adoption of telehealth technologies. CCHP provided non-partisan technical support to the author and sponsor of AB 415.
Assemblyman Logue garnered impressive bipartisan support in the Assembly for the bill, with four Democratic co-authors: Wesley Chesbro (D-North Coast), Cathleen Galgiani (D-Livingston), Richard Pan (D-Natomas), and V. Manuel Pérez (D-Coachella).
AB 415 modernizes California’s landmark Telemedicine Development Act of 1996, to reflect advances in the field since the original law’s passage. It updates the definition of telehealth to reflect the broader range of services in use today, and allows all licensed health professionals in California to engage in telehealth.
Critically, AB 415 creates parity among clinical services, regardless of whether they are delivered in person or via telehealth.
AB 415 does not mandate the use of any telehealth services by health plans or providers, be they public or private. Covered services are still subject to contract negotiations between health plans and providers, and by policy in public insurance programs, such as Medi-Cal, the state’s Medicaid program. AB 415 does not change the scope of practice of any licensed health professional, or change interstate licensure laws.
AB 415 does remove barriers, real or perceived, that have prevented telehealth technologies from being implemented.
What The Telehealth Advancement Act Does
Telemedicine, under the old law’s terminology, was defined as the practice of medicine via live video connections between patients and providers in separate locations, or via “data communications.”
As technological advances resulted in new telehealth treatment options, this legal definition eventually became obsolete—and a barrier to implementation of these new technologies.
For example, while the old law referenced data communications, it did not explicitly include in its definitions the use of store & forward technologies, a prominent type of data communications.
Store & forward connects primary care providers (PCPs) and medical specialists via high-speed, high-definition communications systems that work like emails with attachments.
PCPs transmit patient information and digital images, such as photos, X-rays and video clips. Specialists review the case, and send back diagnoses and treatment plans for the PCP to execute, without the need for in-person appointments. This speeds treatment for patients, removes the need for patient travel, and provides valuable disease-specific education for PCPs.
While store & forward was allowed in a separate section of the old law, the lack of a clear and explicit presence in its definitions created difficulties for providers seeking reimbursement for these services.
For example, Medi-Cal would only cover tele-dermatology, tele-opthalmology and specific, diagnostic tele-optometry services, a restriction that some private payers adopted as well, even though the old law contained no prohibition on the use of store & forward for other specialties.
In addition, the old law did not include chronic disease management programs, which use electronic home monitoring systems to monitor patients’ vital signs.
Studies have shown that these programs help keep patients healthy, allow elderly and disabled patients to live at home and avoid having to move into skilled nursing facilities, and reduce both the number of hospitalizations and lengths of stay—all of which help improve quality of life for patients and contain costs.
Telehealth, the new legal terminology, refers to the technology-enabled delivery of services, rather than a specific medical practice. This allows for a far broader range of telehealth services than the old law, and does not limit future telehealth technologies, because of its encompassing, forward-looking definitions.
Under the old law, telemedicine appointments had to take place only in licensed health care facilities, such as hospitals or physician offices.
There were no explicit restrictions on locations, beyond the licensed facility requirement.
However, Medi-Cal restricted telemedicine delivery to four types of licensed facilities only: hospitals, clinics, physician offices, and skilled nursing facilities.
Some private payors followed suit, and the perception took root that these were the only facilities where telemedicine could occur.
AB 415 explicitly removes limits on the locations for telehealth. This will allow for any type of telehealth to be covered, regardless of where it takes place. This can include patient care management programs that employ home monitoring devices, in-home patient medical appointments, and physician reviews in any location of store & forward cases.
While AB 415 allows for these services to be covered, it does not mandate such coverage.
This allows for substantial expansion of telehealth services. For example, disease management programs often include email or telephone communications between patients and health professionals, to ensure that patients are complying with treatment regimens, and to check up on patients whose home monitoring programs have flagged a problem.
Studies have shown that disease management programs help keep patients healthy, help keep elderly and disabled patients out of skilled nursing facilities, and reduce both the number of hospitalizations and lengths of stay—all of which helps improve patients’ quality of life and contains costs.
AB 415 does not mandate the use of telephone or email in telehealth.
AB 415 expands the definition of health care provider, to include all medical professionals licensed by the State of California.
Under the old law, only these medical professionals could provide telehealth services:
- Clinical psychologists
- Marriage, family and child counselors
- Optometrists (in limited scope)
The Act expands this list to include all professionals licensed under the state’s healing arts statute, including:
- Nurse practitioners
- Physician assistants
- Registered nurses
- Dental hygienists
- Physical therapists
- Occupational therapists
- Speech and language pathologists
- Licensed vocational nurses
This allows for expanded provider use of telehealth services.
For example, dental hygienists can provide oral health services to patients, under the guidance of dentists, with the two professionals communicating via live video hookups.
And similarly, the North Dakota Telepharmacy Project dispenses medication to patients in remote rural areas by having pharmacy technicians do the dispensing, under the guidance of pharmacists, with the two professionals communicating via live video hookups.
AB 415 allows California hospitals to use new federal rules to more easily establish medical credentials of telehealth providers.
An amendment to AB 415 helped clear up confusion among California regulators, over a new federal rule to streamline the process for establishing medical credentials of telehealth providers.
The federal Centers for Medicare and Medicaid Services (CMS) issued the new regulations in July 2011, to speed the approval process of medical credentials for telehealth practitioners.
These federal regulations, called “privileging by proxy,” allow hospitals and other entities engaged in telehealth to accept the credentialing paperwork of each facility’s practitioners. This makes for quicker approvals of practitioners, and eliminates duplicative, expensive, and often cumbersome credentialing processes.
The new CMS rules also allow sites other than hospitals that engage in telehealth, such as physician offices and ambulatory centers, to use the same privileging by proxy processes for telehealth service delivery at a hospital, as long as those services meet the hospital’s conditions of practice.
AB 415 aligns California law with the new CMS regulations. The confusion among California regulators centered on whether existing state regulations were were in conflict with the new rule, and whether the state’s hospitals would still have to go through full credentialing processes for all telehealth practitioners.
First, AB 415 eliminated a Medi-Cal rule requiring providers to document a barrier to an in-person visit before a beneficiary could receive telehealth services, which was widely viewed by providers as a disincentive to its use.
Second, AB 415 removed a sunset date that would have eliminated Medi-Cal coverage of store & forward services for tele-dermatology, tele-opthalmalogy and tele-optometry.
AB 415 changes the requirement of an additional written patient consent specifically for telehealth services to a verbal consent.
Providers found that the old law’s requirement that patients sign a separate, telehealth-specific consent form for any type of service delivered via telehealth.
Providers found that the written consent form stigmatized the use of telehealth, and created an unnecessary barrier to care.
AB 415 replaces the written consent with a verbal consent. This establishes parity between services provided in person, and those provided via telehealth.