Telemedicine could keep older patients out of the hospital. So why hasn't it taken off?

It's easy enough for a doctor on an app to prescribe a birth control pill or an antibiotic. But try getting one to virtually examine your sick mom in a nursing home. Chances are, she'll end up instead being sent to the hospital, where bad problems often get worse.

For years, experts have touted the use of telemedicine as a way to let elder care organizations tap the expertise of geriatricians or other doctors to treat their residents for problems that don't appear to rise to the level of an emergency.

Virtual care seems ideal for treating frail elderly people, for whom a hospital visit can be the start of a decline in health. They get disoriented in emergency rooms, where drug lists and care instructions get lost, beeping monitors and intrusive nurses make it hard to sleep and there's always a risk of acquiring a serious infection.

Research suggests that about two-thirds of hospital admissions from nursing homes were potentially avoidable. In many cases, a video visit would make more sense. But there are few business models employing virtual care because payers don't cover it, experts say.

Since most elder care facilities don't keep doctors on-site regularly, when staff are unsure of a patient's condition, the "default is always to send people to the emergency room," said Tricia Neuman, director of the Kaiser Family Foundation Program on Medicare Policy.

In medicine overall, telemedicine usage is growing; private insurance claim lines for virtual care grew 53 percent from 2016 to 2017, according to a recent report from FH Healthcare Indicators. Increasingly, employers are offering employees access to direct-to-consumer companies like Teladoc and Doctor on Demand, where patients can reach an on-call doctor virtually whenever they need.

But many of those uses are mere conveniences. It's much harder to find a telemedicine doctor in a place where it could really save the health care system money — while protecting the health of patients.

Adoption of the technology in elder care has been "slower than anticipated," said Steven Shill, a partner at the BDO Center for Healthcare Excellence & Innovation.

He cited a host of reasons: Varying reimbursement policies depending on whether elder patients are covered by Medicaid, Medicare, both, or private insurance; providers and payers not fully embracing value-based care payment models; and, occasionally, patients' and practitioners' discomfort with the technology.

The elder care market is so complex that it's hard for telemedicine companies to break in. Call9, a company specializing in such virtual hookups, went out of business in July after about four years. It couldn't get paid enough.

"The inherent benefits of telehealth have been made clear time and time again," Shill said. But, "even if it's a good idea, if you're not going to get paid for it, it becomes a bad idea very quickly."

There are efforts in Washington to fix payment barriers. The Chronic Care Act—part of the 2018 budget agreement—expanded Medicare payments for the virtual treatment of certain conditions such as stroke and end-stage renal disease, including from the patient's home; it also lets Medicare Advantage plans offer telehealth services as basic benefits. But a bill that could have enabled Medicare reimbursement of virtual emergency medicine in skilled nursing homes has failed to advance in Congress.

Call9, which contracted with nursing homes to treat patients virtually on-site, would have benefited from the Reducing Unnecessary Senior Hospitalizations Act of 2018, CEO Tim Peck told POLITICO after the company shuttered. However, many of Call9's partners still operate on a fee-for-service basis, instead of rewarding the value of care, an idea that's popular but hasn't expanded throughout health care yet.

CMS and its advisory commission have historically been concerned that telehealth could end up costing Medicare more money than in-person services, said Winifred Quinn, co-director of AARP and RWJF's Center to Champion Nursing in America. The Medicare Payment Advisory Commission last year recommended a "measured approach to considering the incorporation of telehealth services" into the Physician Fee Schedule and the Medicare program overall.

"Commercial plan coverage of telehealth services is not uniform," the commission's report said, noting that insurers' reasons for adopting coverage "consistently pertained to employer demands and competition rather than cost savings."

Only about 10 percent of nursing homes keep physicians on site around the clock, said Christopher Laxton, executive director of the Society for Post-Acute and Long-Term Care Medicine, a professional organization. They're among the hardest places to staff adequately, Laxton said. "It's hard work, it's not very well paid. ... the people that work at it are frankly sort of mission driven."

Despite challenges, a handful of telemedicine companies have muscled their way into the fragmented market, capitalizing on elder care facilities' low margins and labor needs.

Curavi contracts with skilled nursing facilities and gives them a video cart and on-demand access to a staff of on-call doctors, CEO Alissa Meade said.

The company charges a flat monthly subscription fee for unlimited access to its physicians and nurses, Meade said. She noted that skilled nursing facilities paid on a per-diem basis won't collect that money if the patient is transferred to a hospital; CMS dings hospitals for excess re-admissions.

Few patients and families eschew virtual visits, and most patients would prefer to be treated in place, Meade said. Telemedicine services like Curavi's are designed to be used primarily by nursing staff who want to consult physicians before sending patients out.