By 2020, for the first time in history, the United States will have more people over age 65 than under 5. That trend is projected to continue, such that by 2050 twice as many people will be over 65 as under 5. 

Florida is at the heart of the aging trend. The percentage of Florida’s population age 65 and older in 2015 was 19.4 percent, followed by Maine (18.8 percent). Alaska had the lowest percentage (9.9 percent). 

With today’s increased life expectancies, people who live to 65 can expect to live about 20 more years. The fastest growing subset in this group is past 85. The reasons are clear: People are living longer because infectious disease has been generally contained, while new families are having fewer children. Mortality in older populations has been sharply reduced thanks to the progress in the treatment of cardiovascular disease, cancer and diabetes. 

At the beginning of the 20th century the principal health threats were infectious diseases. Today the main threats are chronic diseases, including heart, stroke, cancer, diabetes, hypertension and dementia. Unlike infections, these conditions are not cured; they are managed. 

The implications for health care are enormous. To treat chronic disease rather than acute illness, the style of medicine will need to change. One-time interventions that correct a single problem will transition into the ongoing management of multiple diseases and disabilities. Doctors and patients will need an ongoing relationship that helps patients manage and cope with illnesses rather than cure them.  

Today’s methods of providing health care are increasingly strained. There are fewer general practitioners and the wait for appointments both with them and with specialists reflects our overburdened systems. Anyone who lives in Southwest Florida can attest to the generally long waits for appointments during the winter season, when the number of visitors increases. 

An aging population has far-reaching impacts on the provision of health care. It is a simple numbers game. There are going to be many more 65-plus individuals in our health care system than any other age group, and they will increasingly suffer from chronic diseases. Their needs must shape how we provide health care. Enter telemedicine.

Telemedicine is the remote delivery of health care services, such as health assessments or consultations, over the telecommunications infrastructure. It allows health care providers to evaluate, diagnose and treat patients prior to or without the need for an in-person visit.  Also called “virtual care,” telemedicine is a rapidly evolving area in which methods of care, availability of insurance coverage and a multitude of other details are starting to take shape. 

Telecommunications may be between a doctor and a patient or between two doctors, such as one in an emergency room and the other a specialist located remotely. Medical specialties that depend largely on images or verbal communications as opposed to physical examination are most amenable to telemedicine. 

Here are a few examples of how telemedicine is being used. Radiology was one of the first medical specialties to use telemedicine. Since radiologists can easily receive images, analyze them and provide feedback to the patient’s physician, some practices and hospitals use remote radiologists. Images can even be sent to radiologists in lower-cost areas so as to minimize expense or to provide an immediate interpretation of the test when no radiologist is on duty.

After a patient has a stroke and is brought to a local hospital, there is a very short window during which appropriate treatment should be given. A neurologist may not be present to decide on the course of treatment. Emergency medicine doctors at properly equipped hospitals can communicate with neurologists at a central site using digital video cameras, Internet telecommunications, robotic telepresence, smartphones, tablets and other technology to decide whether to administer cutting-edge treatments that help preserve brain tissue. 

Research shows that these “telestroke” services can be cost effective. The Congressional Budget Office estimated that although telestroke expansion would result in additional spending in the first year because of additional equipment and treatment, spending would be significantly lower in subsequent years due to a decline in the number of patients who suffer moderate or severe disability or need long-term care.  

Telepsychiatry is helping bring timelier psychiatric care to emergency rooms. An estimated one in eight emergency room visits involves a mental health and/or substance-use condition, according to the Agency for Healthcare Research and Quality. Many emergency rooms are not equipped to handle people with serious mental health issues and do not have psychiatrists or other mental health clinicians on staff to assess and treat mental health problems. A 2016 poll of emergency room physicians found only 17 percent reported having a psychiatrist on call to respond to psychiatric emergencies.

Telepsychiatry is also being used in nursing homes to provide both ongoing psychiatric evaluation and care, and emergency crisis intervention when it may be difficult to find a local psychiatrist to assist.

If a patient with a serious health condition wants to get a second opinion, it may be difficult to find the time and money to fly to a distant center of excellence that specializes in that field. Increasingly, centers of excellence, including Mayo and Cleveland clinics and Partners Healthcare (parent of Brigham and Women’s Hospital and Dana-Farber Cancer Institute), offer remote second opinions by their world-class specialists.

As we transition from office and hospital visits to the increasing use of virtual care, both doctors and patients will need to overcome habituated behaviors. Once this barrier is crossed, many patients are delighted to do away with a variety of inconveniences that are part of today’s system. These can include finding transportation to and from the doctor’s office; negotiating traffic on both legs of the journey; and time spent in a waiting room, which may be filled with other sick people. For snowbirds virtual care could make it easier to provide more effective and efficient care by continuing to have their usual primary doctor involved.

However, there are four major impediments to the greater use of telemedicine: the lack of coverage by health insurance, unfamiliarity to the patient, lack of adoption by some providers, and standard U.S. licensing/credentialing requirements that today are governed by state law and vary from state to state (credentialing).

On February 9, 2018, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018, which includes several key provisions that expand Medicare payment for telemedicine services. Medicare covers almost 60 million Americans age 65 and over, as well as those under 65 who have disabilities. This is tremendously important because commercial health insurers often follow Medicare’s lead. 

The budget bill broadens Medicare’s telemedicine coverage by reimbursing remote telestroke services nationwide. Previously, Medicare telestroke payments were limited to remote and lightly populated areas. It also allows reimbursing for monthly clinical assessments via telemedicine for patients receiving home dialysis nationwide; and additional telemedicine benefits for Medicare Advantage enrollees, as well as telepsychiatry services.

In March 2016, the Florida Legislature passed a new bill designed to set the stage for telehealth commercial insurance coverage in the Sunshine State. It created a formal Telehealth Advisory Council within Florida’s Agency for Health Care Administration (AHCA). It requires AHCA, Florida’s Department of Health, and Office of Insurance Regulation to survey providers, professionals, facilities, and health plans to determine the extent that commercial health plans are actually covering telehealth services in Florida, as well as the reimbursement rates the plans are actually paying to providers. Insurers and providers that refuse to report the information can face fines and penalties. The surveys and research data must be completed and complied by June 30, 2018. 

The Telehealth Advisory Council is charged with taking the data and research findings and delivering a report to the governor and the legislature containing policy recommendations to increase the use and accessibility of telehealth services, as well as any barriers that should be removed. The report is due by December 1, 2018.

TOTI Media has featured a series of articles on how technology is changing our lives. Some of the previous articles tie into this discussion of health care. What happens when a person needs medical care and can’t drive, or when the doctor needs to see the patient in person? As the Jan.-Feb. 2018 article described, not long from now they will be able to summon a driverless car to take them to the doctor’s office and back. If they don’t know how to use a mobile app to order the car, they will be able to use a voice assistant like Alexa or Google Home—they can say “Alexa, call Uber to take me to Dr. Smith” and it’s done! Rather than being separate and distinct, the technologies of driverless cars, medical treatment and new voice-enabled intelligent assistants can combine to solve real world problems in interesting and sometimes unexpected ways.