INDIANAPOLIS – Maybe you wake up on a Saturday with a cough or pink eye.
Wouldn’t it be great to pull out your smartphone, see a physician online and get a prescription sent straight to your pharmacy?
It could become reality under a bill lawmakers are considering in the final weeks of the legislative session. It is already happening on a small scale for some Hoosiers, but it might not be legal.
Telemedicine – or telehealth – is not new in Indiana. It helps provide access to health care for Hoosiers in rural areas, or for anyone at times when traditional doctors aren’t available.
What is new, though, is writing prescriptions without an in-person examination.
"It’s a good bill," said Sen. Patricia Miller, R-Indianapolis. "I’ve been very concerned to realize how many people are engaging in this activity illegally, so I do think we need to address the issue."
House Bill 1263 is up for a Senate vote this week and would give prescribing authority to doctors without first having an in-person exam. But it doesn’t cover all drugs. Controlled substances, such as powerful painkillers, would not be allowed. Instead, the program is aimed more at antibiotics and medications for simple health concerns.
"Indiana is somewhat behind the times," said Rep. Cindy Kirchhofer, R-Beech Grove, author of the bill.
She said it would be geared toward colds and sniffles, urinary tract infections, pink eye and other acute simple conditions – not chronic disease management. And she said it would keep people out of the emergency rooms and avoid backlogs at traditional doctor offices – similar to urgent care clinics already in use.
But there are concerns about whether this model – offered at a cheaper rate by insurance companies and health providers alike – could crowd out the primary care physician relationship.
Richard Feldman, a former state health commissioner speaking on behalf of the Indiana Academy of Family Physicians, testified recently that telemedicine is supposed to be supplemental to having a primary care physician. But nothing in the bill requires that or limits how long a person can continue to use telemedicine without getting a traditional doctor.
"This legislation opens the door for ongoing prescribing and treating without a patient ever seeing a doctor in person. It has the potential of replacing face-to-face care," he said. He sought limitations on how many times a person can be treated via telemedicine without a physical examination "so care is not perpetually electronic in nature."
Indiana is one of 47 states authorizing telemedicine but is the only one of those that doesn’t allow the prescription component. Lawmakers set up a pilot program on prescriptions last year though the startup has been slow and not enough data has been collected yet for a recommendation.
Kirchhofer wants to bypass the pilot – noting that some entities are already writing prescriptions through a legal loophole.
One such example is Teladoc – the largest telemedicine company in the country serving 49 states with 12 million members. Of that, 123,000 are in Indiana. Visits cost $40, and employers who sign their employees up with the company cover some or all of that.
Teladoc spokeswoman Julie Rautio testified earlier this month that the group has had more than 1 million "visits" with no medical malpractice claims. They rely on 2,900 doctors – including 41 licensed in Indiana.
"We treat simple, uncomplicated illnesses," she said. "We are not designed to replace a relationship with a primary care physician."
But she also noted that 40 percent of the members don’t have a primary care physician.
Rautio said Teladoc operates under a cross-coverage provision in the law that allows it to prescribe but said it would be better to have "more legal certainty."
That is what has stopped Anthem from fully marketing its own national telehealth program in Indiana. It uses live video exams and medical histories to treat patients at all hours.
"You wouldn’t believe the overwhelming positive nature of the feedback," said John Jester, vice president at Anthem.
The biggest complaints, he said, are about technology not working or a doctor declining to prescribe.
Sen. Mark Stoops, D-Bloomington, questioned how insurance companies might use telemedicine to pad the bottom line.
He said they could provide free telemedicine visits but require patients to pay out-of-packet for an in-person visit.
"The goal is to minimize cost – not necessarily providing the best patient care," Stoops said.
Denny Darrow, head of the Indiana State Personnel Department, said adding telemedicine for acute conditions like flu and colds is appropriate. In other words, he said it should be used as a stopgap measure.
"It is not our intent to offer lower price settings and drive people to telemedicine rather than their primary care physician," he said.
Miller worked on a significant amendment to the bill that was added last week. It clarifies that all doctors who treat Indiana patients must be licensed in Indiana and governed by the Medical Licensing Board – even if they are out-of-state.
And it said any legal claims resulting from the care would be handled in Indiana courts under Indiana law.