interactive videoconferencing between the beneficiary at a certified rural site and a distant practitioner.

Medicare Policy

Between 1999 and 2001, there was a big shift in Medicare policy. The initial payment policy required two providers (one with the patient at the originating site and one at the distant site for consultation), and the payment was split (75-25). There was little telemedicine at that time in part because of the lack of profitability. In 2001, the requirement for a provider at the originating site was removed. In addition, payment was changed so that the distant provider received the entire payment (according to the fee schedule rate), and a separate payment was added for the originating site—currently, $24. For the distant provider, this payment is equal to what it would make in a face-to-face visit, even though the costs may not be the same. It is important to note, however, that now the total payments are higher. Any discussion of expanding telemedicine widely must consider how much more those visits will cost the taxpayer, not only on an individual basis, but on a number of visits.

Telehealth in Medicare Today

Today, telehealth services are not used much in Medicare. Medicare only pays about $6 million annually for telehealth services. In 2009, about 14,000 beneficiaries had one or more telehealth visits. In 2009, there were about 40,000 telehealth visits, but less than 30,000 bills from the originating site. In part this may be because the originating site was in a patient’s home, which is not a recognized provider site under Medicare.

In 2009, only 369 practitioners provided 10 or more telehealth services to Medicare beneficiaries, and most of these were mental health services. There are many possible reasons for these low usage rates. For example, extra time may be required for the telehealth visit. Some specialists (e.g., dermatologists, cardiologists) may think their income will be higher by performing procedures during that time. They may already be so busy with face-to-face patient loads that they do not perceive the need to add more patient populations. Also, any additional administrative cost might be another hindrance.

Psychologists, psychiatrists, and clinical social workers accounted for 49 percent of the health care professionals who provided 10 or more telehealth services in Medicare. Physician assistants, nurse practitioners, and clinical nurse specialists accounted for 19 percent of the practitioners, and family medicine and internal medicine physicians accounted for 7 percent. This is somewhat surprising since telehealth is largely promoted as a mo-



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