Taking a stand against the rapidly expanding use of telemedicine, the Texas Medical Board voted Friday to sharply restrict the practice in the state, siding with organizations representing doctors over the objections of industry representatives who said the new rules would reduce access to medical care at a time of increasing demand.
The vote was the latest salvo in a four-year battle between the state board, which licenses and regulates doctors, and Teladoc, a national company based in Dallas that provides telephone or video consultations with doctors on its staff, typically for routine problems like urinary tract infections, sore throats and rashes.
It also comes as companies like Teladoc, helped by enthusiastic investors and rapid advances in technology, are seeking to expand around the country, promoting their services as a convenient, inexpensive alternative to the emergency room, retail clinics or doctors who do not work nights or weekends. Many states are loosening restrictions on telemedicine, and requiring insurers to pay for it, citing doctor shortages and pressure to increase convenient access to medical care, partly because of the Affordable Care Act.
Texas, however, is moving in the opposite direction. The Texas board already required doctors to establish a relationship with patients before giving a diagnosis or prescribing drugs.
But on Friday, it changed its rules to state that "questions and answers exchanged through email, electronic text, or chat or telephonic evaluation of or consultation with a patient" are inadequate to establish a doctor-patient relationship. The move significantly tightens rules that already preclude video consultations except under a narrow set of circumstances.
The Texas Medical Association and other groups representing doctors in the state strongly supported the new restrictions, citing concerns about patient safety. In a letter to the board, the association said it "supports the use of telemedicine that can provide safe, high-quality, timely care," but that safeguards must be in place "to protect patients and ensure telemedicine complements the efforts of local health care providers."
But Jason Gorevic, the chief executive of Teladoc, said in a statement that the new restrictions were "a huge step backward for Texas," eliminating "a safe, affordable and convenient health care option that many have depended on for more than a decade."
The new restrictions do not outright ban telemedicine, however. Doctors will still be able to treat patients by phone or video from another location under certain circumstances. For example, patients will have to be at a hospital or clinic, with a second health care provider there to "assist." The new restrictions do not apply to mental health visits, most likely because of a continuing shortage of psychiatrists.
Telemedicine companies either directly charge consumers a flat fee, typically around $40 per consultation, or contract with employers or insurers to provide the consultations as a covered benefit. But they emphasize that they cannot treat serious problems or medical emergencies, and that they are meant to complement, not replace, people's relationships with their doctors.
"This is going to quickly emerge as one way to relieve the demand pressures that are being put on the system," said Ceci Connolly, managing director of the PriceWaterhouseCoopers Health Research Institute. "We're just getting started."
Texas is among a handful of states that still require an in-person exam before a telemedicine consult can take place, according to the American Telemedicine Association, a trade group in Washington. Other states have vaguely worded policies that are not clear on whether an in-person visit is needed first.
In a recent interview, Mr. Gorevic said Teladoc's national network of 700 board-certified physicians receive special training in how to conduct telemedicine consultations and follow clinical guidelines that are "specific to telehealth." The company, which operates in every state except Arkansas and Idaho, has seen rapid growth in demand for its services, he said, with almost 300,000 consultations last year, double the number in 2013. It has more customers in Texas than in any other state.
The company says its doctors are available 24 hours a day, seven days a week. When a customer requests a consultation by calling or going to the company's website, Mr. Gorevic said, a doctor licensed in the person's state responds within 10 minutes on average. Its doctors do not prescribe narcotics, other controlled substances, or what it refers to as "lifestyle drugs," such as Viagra.
Teladoc's conflict with the medical board started in 2011, when the board threatened to discipline the company's doctors for prescribing drugs to patients they had not seen in person. Teladoc sued, accusing the board of changing its rules without going through the proper process. Late last year, a state appeals court sided with Teladoc, which led the medical board to issue an emergency rule in January. Teladoc won a temporary injunction while the board went through its formal rule-making process over the last few months.
The new restrictions are to take effect in June. Before voting on them, Frank Denton, an investment executive from the Houston area who was the only board member to oppose them, said telemedicine was the "least desirable" way to deliver health care but that "the public should have the right to use that option."
But another board member, Dr. George Willeford of Austin, expressed the opinion of the majority when he said he worried that telemedicine, unless properly regulated, could weaken doctor accountability to patients. "I'm terribly, terribly worried about the absence of responsibility and accountability," he said.
That view was echoed at a public hearing on Thursday by Dr. Steven Yount, a family practice doctor in Bastrop, near Austin, who said that hands-on diagnosis and treatment was essential.
"A patient encounter that from the very get-go removes many of the abilities of a physician to comprehensively look at any given patient is of a lower quality," Dr. Yount said.
But most of about a dozen people who spoke at the hearing, including several Teladoc officials, opposed the change. Bill Hammond, chief executive of the Texas Association of Business, said the restrictions would "drive a stake through the heart" of telemedicine in Texas at a time when thousands of small businesses are looking for innovative solutions to combat rising insurance costs and to provide health care to employees.
"This proposal is bad for business, bad for health care, bad for consumers," Mr. Hammond said.
An article on Saturday about a vote by the Texas Medical Board to limit the use of telemedicine referred incorrectly to Jason Gorevic's role with Teladoc, a national company that provides telephone or video consultations with doctors. While Mr. Gorevic is Teladoc's chief executive, he is not a founder of the company.
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