On a recent trip to Chicago, Patti Broyles felt like she was looking at the world from the bottom of a fish bowl.
"This weather was really cold and rainy and I had a lot of pressure in my sinus areas," Broyles says.
Since she was nowhere near her primary care doctor in Dallas, she called Teladoc, the largest telemedicine provider in the U.S., for advice. Patients whose employers or insurers have deals with the Dallas-based company can call any time and be connected with a physician on duty within minutes.
"The rules, as they're written today, only allow a physician who has seen a patient in person to interact with them remotely. That's basically saying you can't go shop anywhere else."
Broyles says the doctor on the call gave her a prescription for antibiotics that soon cleared up her sinus infection.
Jason Gorevic, Teladoc's chief executive officer, says such encounters use familiar technology, "whether it's your cellphone, your laptop that has a webcam built in to it, or simply the phone."
In Texas, hundreds of employers offer Teladoc's services to more than 2 million employees, Gorevic says.
But new rules from the Texas Medical Board could make it a lot harder for people like Broyles to get antibiotics that way. In response to the board's restrictions, Teladoc has filed a lawsuit that accuses the medical board of artificially limiting supply and increasing prices.
"No one would think, if they showed up at their doctor's office, they would go back to a room, have the doctor stand on one side of the door, they would stand on the other, tell the doctor their symptoms and the doctor would slip a prescription out from under the door. No one would think that was good care."
"The rules, as they're written today, only allow a physician who has seen a patient in person to interact with them remotely," Gorevic says. "That's basically saying you can't go shop anywhere else."
The rules do allow for certain exceptions that would permit a physician to diagnose or prescribe medications via phone or video. It would be OK, for example, if the patient were at a medical clinic, or another health care worker were with the patient and could do a sort of surrogate exam. There's also an exemption for remote mental health visits.
Mari Robinson, executive director of the Texas Medical Board, says the rules aren't meant to stifle competition. They're meant to ensure patient safety.
"How can a physician make an accurate diagnosis when they have no objective diagnostic data?" Robinson asks. "All they have is what the patient has told them.
And that's not enough information, she says.
"No one would think if they showed up at their doctor's office they would go back to a room, have the doctor stand on one side of the door, they would stand on the other, they would tell the doctor their symptoms and the doctor would slip a prescription out from under the door. No one would think that was good care," says Robinson. "That is exactly the same as doing it over the telephone or over some system where a physician can't get objective diagnostic information."
But Dallas health care attorney Brenda Tso says that if you peek behind the curtain, the strict rules aren't just about patient safety.
"Doctors are trying to protect their practice from telemedicine, basically," she says.
Still, Tso says she thinks Teladoc's motivations are also financial.
The medical board is not suggesting that telemedicine should be completely stopped, Tso says. "That would be stupid. And nobody is saying that. Now, what the Texas Medical Board and the doctors are saying [is], 'Well, we should use it in a limited sense, as long as it doesn't affect the standard of care.' "
While the Texas Medical Board doesn't think it's good practice for patients to be sending photos, videos and text messages to unfamiliar doctors, attorney Rene Quashie points out that other states permit all those activities.
"If you look at states like Virginia, Maryland and New Mexico, they have laws and regulations that really facilitate the greater use of telemedicine," Quashie says. "Texas is not one of those states."
He says that maybe especially in a state like Texas, where 200 counties are considered medically underserved, and more than a dozen counties have just one primary care doctor — there's a larger role for telemedicine.
"There's a huge underinsured population in Texas," Quashie says. "Even people who have insurance, sometimes have problems accessing care. So we're balancing access to care along with patient safety issues — misdiagnosis and over-prescription. But we also want to allow companies to innovate in this space."
Access to doctors is the main reason insurer Blue Shield partnered with Teladoc in California. Executive Vice President Janet Widmann says that, initially, telemedicine was meant to help rural members reach specialists.
"Now there's quite a bit of interest from our members in having the convenience of a telehealth visit. Folks want that," she says.
By next year, 800,000 of the Blue Shield of California's 3.5 million members will be able to use Teladoc.
In Texas, the medical board has already received more than 200 comments on the change of rules. It says key players, such as the Texas Medical Association, support the stringent regulations. Teladoc points out, on the other hand, that the vast majority of the comments were in opposition. The new rules governing virtual visits were supposed to go into effect June 3rd, but have been delayed until the case goes to trial.
This story is part of NPR's reporting partnership with local member stations and Kaiser Health News.
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