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14 Jun 2018

Telemedicine use spikes during natural disasters

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Nemours CareConnect is a telemedicine service available to Floridians. (Nemours Children’s Hospital)
If Dr. Timothy Hendrix had any lingering doubts about telemedicine, they were erased during last year’s hurricane season.
As Central Florida began to brace for the arrival of Hurricane Irma in September, and doctors’ offices and urgent care centers closed, Nemours Children’s Hospital and Florida Hospital decided to offer their telemedicine services for free.
Both services were flooded with calls from people seeking a virtual visit with a doctor.
There was a 554 percent jump in the number of people who installed the Nemours’ CareConnect app during the days before, during and after the hurricane.
“We saw 270 kidsduring the day-and-a-half before and the day-and-a-half after the hurricane,” said Carey Officer, operational vice president of Nemours CareConnect and the Center for Health Delivery Innovation at the health system.
Florida Hospital’s eCare went from an average of four to five calls a day to 40 to 50 a day, said Hendrix, medical director of Florida Hospital Centra Care urgent care centers.
Hendrix has been practicing medicine for a quarter century and until two years ago, when Florida Hospital introduced its eCare consumer telemedicine service, his patient exams involved the actual presence of the patients in his office.
“I was resistant to the whole idea of eCare,” Hendrix said. “I’m an old-school doctor.”
But then in the days leading up to and after Hurricane Irma, he saw how a virtual doctor visit was the saving grace for the worried parents or the elderly who couldn’t access their doctors.
“It really made me realize the potential of [telehealth] in medicine and the potential ways we can use technology in unique situations like natural disasters,” said Hendrix. “I’m a total convert.”
Neither telemedicine is new, nor is its use during natural disasters. But advancements in technology and widespread access to smartphones and tablets have pushed telemedicine beyond the hospital walls and available to the masses.
Most current telemedicine services are provided via secure apps. Not all insurance companies cover telemedicine calls, so instead of waiting for new regulations and laws, the companies charge patients a flat fee, usually less than $100, to give them access to a provider. Depending on the service, the conversation may start with text messages and turn into a video call for further assessment.
The use of telemedicine has grown rapidly, with more than 1.2 million visits reported nationally in 2015, according to the policy think tank RAND Corporation.
Last year’s active hurricane season helped establish telemedicine as a viable alternative to in-person doctor visits during natural disasters.
In addition to Nemours and Florida Hospital, at least five other telemedicine companies, including Doctor on Demand, MDLIVE, Teladoc, American Well and LiveHealth Online also offered free services to consumers during the 2017 hurricane season, according to a study by RAND Corporation.
The study, which only analyzed data from Doctor on Demand during the month after Hurricanes Harvey and Irma, concluded that telemedicine services are a new way to deliver routine care to people in immediate aftermath of natural disasters.
They study found that 63 percent of the more than 2,000 people who called Doctor on Demand after the hurricanes were first-time users.
It also highlighted another advantage to the use of telemedicine during disasters: out-of-state providers can be tapped to expand workforce quickly.
Doctors who were outside the affected states handled nearly half of the visits to Doctor on Demand, the study found.
Data show that most of the patient calls, during a disaster or other times, are for routine concerns such as common cold, respiratory problems, rashes and infections like pink eye.
“It’s the same stuff that I see in the office, except that I sometimes asked them to do the exam. And you function more based on ‘Can I do this on this visit or should I ask them to see a doctor?’” said Hendrix.
He said he had to refer less than 5 percent of his eCare visits for a complete workup at the doctor’s office.
That said, telemedicine has its pitfalls.
Timely access to a pharmacy to fill prescriptions remains an issue. What if the patient is trapped at home? And what if all area pharmacies are closed? Can hospital pharmacies handle the outpatient demand?
And what if the patient — or doctor on call — doesn’t have access to power and Wi-Fi?
“[Telemedicine] is a good idea, but unfortunately, the very nature of a disaster makes the delivery of the care problematic,” said Dr. Antonio Velardi, director of critical care at Orlando Health’s Health Central Hospital.
In preparation for the hurricanes last year, Hendrix made sure that the eCare team had power and backup generators to get through the outage. He had access to Wi-Fi and could juice up his phone to answer calls, but still he had no power at home.
“At one point I realized I was answering calls in the dark in a T-shirt,” he said with a chuckle.
So maybe better lighting would be something to consider for the coming hurricane season. But there’s not much else he would need to do to prepare, he said.
“The beautiful thing is that [telemedicine] is so easy. It’s already up and running, so it’s just a matter of having doctors and nurse practitioners available to cover it,” he said., 407-420-5158, @naseemmiller

Reposted by Physician Licensing Service, June 14, 2018



30 May 2018

Do Most Hospitals Benefit from Directly Employing Physicians?

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How can hospitals and health systems generate a return on their investment in their physician enterprises? may18-25-82143495-Peter-Dazeley

According to the most recent figures, from the American Medical Association, over 25% of U.S. physicians practiced in groups wholly or partly owned by hospitals in 2016 and another 7% were direct hospital employees. Yet, according to the Medical Group Management Association, hospitals’ multi-specialty physician groups lost almost $196,000 per employed physician.


As a result, some larger health systems’ physician operations are generating nine-figure operating losses, which are major contributors to the deterioration in hospital earnings.  It is time for hospitals or health systems to rethink their strategy for their physician enterprises.


Let’s first revisit why independent physicians were receptive to becoming employees and why hospitals and health systems felt the need to hire them.


The surge in hospital employment of physicians predated Obamacare by at least six years, and had two key drivers. The first was independent baby-boomer physicians — particularly those in primary care — found themselves unable to recruit new partners. Newer physicians, heavily burdened by student debt, were not inclined either to take on entrepreneurial risk or the 60-hour work weeks independent practice entailed.


The second was cuts in Medicare payments for office-based imaging. Thanks to the Deficit Reduction Act of 2005, specialties such as cardiology, orthopedics, and medical oncology that relied on the revenue that imaging generated were hit hard. As a result, many found it advantageous to be employed by hospitals. Under Medicare rules, in addition to professional fees, hospitals can charge a Part B technical fee for their services and therefore can pay practitioners more than they could earn in private practice.


Then, beginning in 2009, the Obama administration’s policies increased the exodus of physicians from private practices to health systems. The “meaningful use” provisions of the HITECH Act of 2009 provided both incentives and penalties for physicians to adopt electronic records, but hospitals and very corporate enterprises had more resources to comply with meaningful-use requirements.


The value-based-payment schemes created by the Affordable Care Act also markedly increased documentation requirements and, as a result, the overhead of practices, driving more physicians into hospital employment models.


There have been a number of reasons hospitals have been hiring physicians. Some, particularly those in rural areas, had no choice but to turn physicians into employees. Retiring independent physicians were leaving large gaps in care in their economically challenged communities. Consequently, hospitals that did not step in to fill the gaps were in danger of closing.


Separately, some hospitals or systems sought to grab business from their competitors by acquiring physicianswho hospitalized their patients at competing facilities. These physicians’ inpatient and, particularly, outpatient imaging and laboratory volume generated additional revenues for the acquiring hospital or system.


A third apparent motivation was to corner the local physician market in order to obtain more favorable rates from health insurers. This seemed to have been a major rationale for St. Luke’s Health Systems acquisition of Seltzer Medical Group, Idaho’s largest independent, multi-specialty physician practice group, which led to an anti-trust action.


Yet another reason for making physicians employees was to position the organization for capitated, or value-based, payment. Hospitals believed that “salarying” physicians would help control clinical volumes and thus make it easier to perform in capitated contracts.


Finally, some hospital and system CEOs were tired of negotiating with local independent physician groups or national physician-staffing firms like MedNax and TeamHealth over incomes and coverage of the hospitals’ 24/7 services such as the emergency department, the intensive care unit (ICU), and diagnostic services like radiology and pathology. Building an in-house staff of physicians seemed like an attractive alternative.


Many health systems have gotten into trouble because their strategic rationale for hiring physicians became a moving target.  A hospital system we followed morphed from a ““grab market share” strategy to a “respond to competitive acquisitions” strategy to a “bailout” strategy for loyal independent physicians to a “increase bargaining power with payers” strategy to a “position for value-based care” strategy over a period of eight years. By the time it was done, it was the proud owner of a 700-plus physician group and losses of more than $100 million per year.


Hospitals lose money on their employed physicians because physicians’ compensation plus practice expenses and corporate overhead significantly exceed the collections of practices. These direct losses are, to a degree, an artifact of accounting, because hospitals frequently do not attribute any bonus for meeting “value-based’ contract targets, or incremental hospital surgical, imaging, and lab revenues to physician practice income.


However, even factoring in the accounting issues, much of the losses are attributable to “hosting,” rather than managing, practices effectively.  Many systems employing physicians have done so without developing a cohesive physician organization and lack standardized staffing and operational support functions, such as effective purchasing and supply chain operations, effective scheduling systems, and centralized office locations.


Managing up the return, rather than managing down the loss, is the key to a successful physician strategy. Here’s how to do that.


Establish a clear strategic goal and a target return on investment. Physicians reside at the core of any successful health system. Yet as the Cheshire Cat said in Alice in Wonderland, “If you don’t care where you are going, then it doesn’t matter which way you go!” If you establish strategic goals for the physician enterprise, then the physician organization can be sized and located appropriately. As a result, the physician group may end up either a lot smaller or with a more defensible specialty and/or geographic distribution. Management should then quantify and budget the expected return on the practice’s operational loss.


Strengthen operations. Effective management of the physician group then becomes the essential challenge. For example, revenue-cycle issues such as inconsistent coding or missing data often damage the profitability of the medical group. Are systems in place to assure that medical bills are defensible and correct, and that patients understand what they owe and agree to pay? Seeing that encounters are adequately documented and translated into a fair and timely bill that patients are willing to pay is not rocket science. The return on investment for getting the revenue cycle right is often 3X to 5X.


Revamp compensation and incentives. Medicare’s policy for paying employed physicians will likely come under fresh scrutiny during the Trump administration. It is possible that Medicare’s relatively favorable payment for hospital-employed physicians will be reined in. If that happens, it might require a painful revisiting of employment contracts when they come up for renewal.


Performance incentives in those contracts should also match the strategic goals established above. For example, compensating physicians through a production-based model that encourages them to increase visits, procedures, or hospital admissions, while value-based insurance contracts (like those for accountable care organizations) demand reducing them could damage the overall performance of the health system.


Pursue reality-based contracts with insurers. The Affordable Care Act ushered in a profusion of narrow network, performance-based contracts with private insurers, with significant front-end rate concessions by hospitals. These discounts often far exceeded the potential rewards from the “value based” incentives in the contracts! Larger health systems also rushed to assemble “clinically integrated networks” (CINs), comprising their employed and contracted physicians as well as private practitioners in their markets, to participate in these new contracts. Treating physician group losses and CIN expenses as loss leaders for value-based contracts and then losing yet more money on those contracts, as is happening in many places, doesn’t make sense.


Both enrollment and financial performance under these contracts have been disappointing in most markets. Reviewing and pruning back these contracts, or renegotiating them to provide more adequate rates or to compensate hospitals for patient non-payment is an essential element of an effective physician-enterprise strategy. Hospitals and health systems also should ask: “Is the CIN functioning as intended? Is it adding value that patients notice or is it just an additional layer of administrative expense without compensating benefits for clinicians or patients?


Motivate employed and independent physicians. Finally, hospitals and systems must understand the value they are creating not only for their employed clinical workforce but also for the two-thirds of their physicians who are not full-time employees — those who are contracted, independent participants in CIN’s or in part-time administrative roles. What would motivate all these physicians to want to work with the organization over the long term?


Hospital and systems need a unified physician strategy and operating model that encompasses all these diverse arrangements. Beyond that, they must  engage their physicians in planning and organizing care. Physician are complex, highly trained professionals. They cannot be mere employees; they must be owners of the organization’s goals and strategies.



Reposted by: Physician Licensing Service

Written May 29, 2018 by:



25 May 2018

How telemedicine is providing in-home psychotherapy for veterans

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At the American Telemedicine Association conference in Chicago, clinicians came together to discuss how video-to-home technology can help deliver psychotherapy to veterans.

veterans affairs telehealth


Despite the fact that the Department of Veterans Affairs is the largest healthcare system in the country, for a lot of veterans coming into to a clinic, is difficult. It would be impossible for a clinic to be in every veteran’s neighborhood — that’s where telemedicine comes in.


At the American Telemedicine Association conference in Chicago, clinicians came together to discuss how video-to-home technology can help deliver psychotherapy to veterans. But it turns out that distance isn’t the only hurdle in treating patients with living with mental health disorders.


Terri Barrera, a research psychologist at the Department of Veterans Affairs, said that she works with patients with Obsessive-Compulsive Disorder. The condition causes patients to have recurrent unwanted thoughts as well as ritualistic behaviors, which the person feels drawn to complete in order to get rid of the thought, according to Barrera. Patients usually experience triggers, such as germs.


All of this means that for some patients, coming into a hospital or clinic creates an extra layer of anxiety. But Barrera discussed how the “gold standard” of care can be implemented in video-based therapy.


Currently, exposure therapy, where a client is exposed to the stimuli that is linked to the obsession or fear is introduced, is one of the main treatments, along with preventing the ritual.


“What I love about video apps for OCD, is not only is it increasing access to care but exposure therapy for OCD requires 20 sessions and usually 90 minutes and that is a lot of time,” Barrera said. “These patients also have very high anxiety levels and some are unable to come into the clinical because of anxiety.”


She discussed a case study involving a young female veteran who had a fear of blood, illness, dirt and germs.


“With ‘Mary’ the hospitals were a huge trigger for her, so coming into the hospitals [wasn’t] an option for getting her the care she desperately needed,” Barrera said.


Instead “Mary” was able to get the services she needed in her home with virtual based care. It also let her practice exposure therapy with stimuli that she faced every day. For example, she didn’t like to touch any mail that the mail person touched, so the therapist was able to walk her through this practical application, Barrera said.


Remote therapy is also being used to help veterans who have experienced sexual trauma, whether that be in the form of assault or harassment. One in four women and one in 100 men who serve in the military experience some type of sexual trauma, according to Julianna Hogan, a psychologist and research health scientist at Baylor College of Medicine who works with veterans and presented during the session.


Many of the veterans who have experienced the trauma aren’t in a place where they want to discuss the event, she said. But there are options for people who aren’t ready to revisit the experience but need tools for managing their symptoms. Hogan discussed a specific tool called webSTAIR, which is a self-guided platform where the user can work interpersonal relationships and coping strategies. Users of the tool can also add their therapist or coach.


The goal is to eventually get people to a place where they can talk about their experience with a therapist.


Addiction is another concentration where clinicians have tapped into telemedicine. Currently, Jan Lindsay, a psychologist at the Department of Veterans Affairs, uses telemedicine to treat people with addiction. Currently 11 percent of veterans who are receiving care at the VA have a substance abuse disorder; however, Lindsay said during the panel that this is a relatively conservative number.


Lindsay went on to talk about a patient who was referred to her by the Veterans Justice Operation, after he was arrested. The patient was a combat veteran in his early 30s and had served in both Afghanistan and Iraq. She was able to meet with him over video in his home, but it was a multifaceted approach during which she worked with multiple providers on the case.


This type of psychotherapy was also implemented for a woman who was living with homelessness. She was able to use a tablet at her shelter to attend therapy sessions for her addiction, after refusing to come in for treatment.


While all of these therapies have given new avenues for patients to receive care, there are even more technologies coming out, the panel noted. But as more innovation come into the space, the clinicians said it was paramount that the therapies get tested and vetted on a veteran community.


Original by Laura Lovett – May 03, 2018 – 10:07 AM


Reposted by Physician Licensing Service
16 Apr 2018

ATA18 – Visit our booth at the American Telemedicine Assoc. Conf. in Chicago

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The largest and most important gathering of telemedicine professionals in North America will take place in less than 2 weeks in Chicago, Illinois, April 29th through May 1st.

Physician Licensing Service will be there to answer questions and advise on multi-state acquisition of medical licensure and to share proven effective risk management techniques learned over 21 years of licensing medical professionals.

What is telemedicine?


How can I benefit from using technology to interface with my preferred health care professionals?


Why are so many people talking about telemedicine and will it really benefit my family?


What do I gain and what do I lose from using advanced telemed technology to service my family’s heath care needs?



These are questions that many of us have asked when viewing the dizzying array of new technology available for individuals and families to use when communicating with doctors and hospital staff. We have all seen how modern technology has revolutionized how we communicate with our friends, family and coworkers. The upcoming conferencing discussing these issues in Chicago will be a great place to find answers.


Come see our booth at ATA18 in Chicago this April 29th through May 1st and find out about our Physician Licensing Service special promotion for multi state acquisition. For details please email Tony at or call 888-551-2140.




05 Apr 2018

Intermountain Turns Telehealth, mHealth Into a Connected Care Platform

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By gathering 35 different telehealth and mHealth services into one connected care platform, Intermountain Healthcare aims to make care coordination and management and community effort.

Intermountain Healthcare has decided to bring all of its telehealth and telemedicine programs together under one virtual roof.


The 22-hospital, 180-clinic health system, based in Salt Lake City, recently announced the launch of Connect Care Pro, which is being billed as one of the nation’s largest virtual hospital services. Officials say the platform, in the planning stages for five years, seeks to gather together Intermountain’s 35 digital health programs.


“We decided that we needed to bring it all together under one entity,” says James Sheets, the health system’s Vice President of Outreach Services Development. “We all want to be singing from the same sheet of music from now on.”


The naming of the new service, Sheets says, is quite deliberate.


“Healthcare is focused so much on virtual or tele- programs, but this is more than just a video visit,” he says, running down a list that includes telestroke, telehealth programs for behavioral health and newborn critical care, telepharmacy services and digital health services that make use of connected health devices. “Connected kinda defines what we’re doing.”


It actually defines what many hospitals and health systems have been doing for the last few years: launching telehealth and mHealth programs and pilots here and there, defining specific goals or targeted populations, and building up a collection of services that don’t integrate easily. By moving to gather those services together, Intermountain is moving into what many believe to be next phase of telehealth.


“We’re gathering together what’s been a quite fragmented (collection of services), which will allow us to grow and scale up even more.”


Connect Care Pro, which will be coordinated out of a 20,000-square-foot facility in nearby Murray, will also bring into focus a particular goal of Intermountain and telehealth in general – to extend care coordination and management outside the health system and help small hospitals and medical groups keep their patients.


“We’re building relationships with communities,” Sheets says. “We can now export some of our expertise. Healing and health is connected to the support you have around you.”


That philosophy has already proven its value. Intermountain officials say their connected care program allowed a small hospital in the southern part of the state to connect via telemedicine for a consult on a sick baby. That critical care consult negated the need for a transfer to Intermountain’s newborn intensive care unit in Salt Lake City, a trip that would have cost more than $18,000 and caused even more stress for the family.


“Our goal is to keep care in the communities,” says Sheets, noting Intermountain’s telehealth programs not only encompass the health system’s own hospitals but nine others outside the system. And there are plans to push that envelope even further, with remote patient monitoring and chronic care management programs and services that extend to new sites, like schools, prisons and skilled nursing facilities.


One of those nine hospitals outside the Intermountain system is Kane County Hospital, an independent facility located in Kanab, near the Arizona border. In a press release provided by Intermountain, the hospital’s chief nursing officer, Charlene Kelly, RN, BSN, said her hospital has used a telemedicine platform for potentially life-saving mental health evaluations.


“Kanab has had one of the highest suicide rates in the state, not including patients that come to us from our border town in Arizona, and we don’t have a crisis worker here,” she said. “Trying to place a patient who has not had a crisis evaluation was next to impossible.  With crisis care from Intermountain Healthcare, patients receive that crisis evaluation in less than an hour, and if the crisis worker recommends inpatient treatment they assist in placing the patient.”


“Our providers just love having this service available,” she added.


Original article written by Eric Wicklund and posted on March 6, 2018.

Reposted by Physician Licensing Service.


26 Mar 2018

Senators Include Telemedicine in New Bill to Modernize the VA

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A proposal to enable VA doctors to treat veterans via telemedicine no matter where they live is included in a new VA modernization bill submitted by Sens. John McCain and Jerry Moran.

Photo supplied by Thinkstock


A new bill that seeks to modernize the oft-criticized Department of Veterans Affairs includes a provision allowing VA doctors to treat veterans via telemedicine no matter where they live.



The 125-page Veterans Community Care and Access Act of 2017, filed this week by Sens. John McCain (R-Ariz.) and Jerry Moran (R-Kansas), uses the same language as that featured in the Veterans E-Health & Telemedicine Support (VETS) Act of 2017 (H.R. 2123), which was passed by the House last month and now awaits a Senate vote.



Both bills would allow VA-affiliated practitioners to treat veterans through telemedicine in any state, bypassing state licensure laws, as long as they follow established healthcare standards and have an active and unrestricted state license.



Both bills also call on VA Secretary David Shulkin to report back to Congress within a year “on the effectiveness of the use of telemedicine by the Department of Veterans Affairs.”



Shulkin has included the same telemedicine provision in his “Anywhere to Anywhere VA Health Care” program, unveiled in September and backed by the Justice Department.



While the VETS Act, co-sponsored by Reps. Julia Brownley (D-Calif.) and Rep. Glenn Thompson (R-Pa.), sailed through a unanimous House vote in early November, its companion bill in the Senate, submitted by Sens. Joni Ernst (R-Iowa) and Mazie Hirono (D-Hawaii), still awaits a vote – not a sure bet, given the Senate’s busy workload and a lack of progress on single-item bills.



With their bill, McCain and Moran are tacking the telemedicine provision onto a much larger effort to modernize the VA and repair its less-than-stellar image in serving veterans.



The bill would establish a Veterans Community Care Program that coordinates healthcare inside and outside VA health systems for the nation’s veterans, including establishing access and quality standards, safe prescribing standards and a walk-in care protocol. It also calls on VA facilities to coordinate care with non-VA providers by sharing medical records and determining reimbursement.



“In the wake of the scandal in care at VA hospitals in Phoenix and around the country, we vowed to guarantee our veterans timely access to quality treatment,” McCain said in a joint release issued by the two senators“The Veterans Choice Program was the first step in delivering on that promise, but much more needs to be done to provide all veterans a choice in when and where they receive care.”



“Our bill would strengthen and improve the core elements of Choice by consolidating and streamlining the VA’s community care program,” he continued. “Moreover, the bill would deliver long overdue, critical reforms to the VA, including commonsense reporting standards that ensure cost-efficient care to our nation’s veterans.”


“Demand has demonstrated that veterans want and need healthcare options in their communities, but there must be reform at the VA to create a system that works for them,” Moran added. “This joint effort to reform the VA will offer veterans an integrated healthcare system within their community that reduces red tape, enhances their quality of life and provides care that is worthy of their service and sacrifice.”



The VETS Act has received support from a broad range of organizations, including the American Telemedicine Association, American Medical Informatics AssociationFederal Trade Commission, Health IT Now, the American Academy of Family Physicians, the College of Healthcare Information Management Executives (CHIME), Teladoc, Oracle, the American Psychological Association, the Brain Injury Association of America, the National Association of Social Workers and the University of Pittsburgh Center for Military Medicine Research.



The AAFP’s support was guarded, however. The organization said it would support this specific bill to improve veterans’ access to much-needed healthcare services, though it “still strongly supports state-based licensure and regulation of physicians and other healthcare providers as well as the states’ ability to regulate the practice of telehealth in their state.”



Among those opposed to the provision is the Medical Board of California.



In an Oct. 30 letter to Shulkin, the board said the VA secretary’s proposed rule “would undermine California’s ability to protect healthcare consumers, as the board will have no ability to discipline VA providers that are licensed in another state and providing telehealth outside of a VA facility in California, as they do not hold a license to practice in California.”



“Although the board believes that telehealth is a useful tool that can be used to provide appropriate service to patients in California, the board believes that it is very important for physicians treating patients in California to be licensed in California,” the letter concluded.



Original posted by Eric Wicklund on 12/05/17

16 Mar 2018

PLS Announcement: Now licensing all mid-levels. Physician Assistants, Nurse Practitioners, etc.

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Physician Licensing Service is pleased to announce the creation of our mid level team, designed to service the medical licensure needs of Physician Assistants and Nurse Practitioners(APRN).

Over the last 20+ years, we have provided time management services for working medical professionals. Time is a resource that is very coveted in modernity and our business model has been designed to keep working medical professionals focused on what makes them successful. Tens of thousands of our clients have chosen to hire out the 20+ hours of mindless phone calls and paperwork necessary to acquire a medical license in any given state.



THIS NEW SERVICE for Physician Assistants and Nurse Practitioners is now available in all 50 states in the United States for a one time low cost fee. For details on timeframes and costs associated please contact our Business Director, Tony Hendricks, at 801-449-9196 or



Call or email us to find out what we can do to save you time and money through our new mid level service offering.

05 Mar 2018

Can Telemedicine Be Both Cost Efficient and High Quality?

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Health insurance companies are encouraging patients to turn to apps and virtual visits to save time and money, but some patients end up not getting the care they need.

Erica Jensen, with her 5-month-old daughter, Charlee Jaques, by her side, video conferenced with her doctor, Dr. Marie McDonnell, from her mother’s home in Wilmington, Mass., on March 15, 2016.(DINA RUDICK/THE BOSTON GLOBE VIA GETTY IMAGES)


LAST MONTH, JENNIFER McMurrain of Bartlesville, Oklahoma, didn’t go to the doctor – she requested one by app. “I had horrible sinus pressure in my head,” she said. “I knew immediately it was a sinus infection and to get over it I’d need a round of antibiotics and prednisone.” So McMurrain relied on Teladoc, a telemedicine provider that partners with Aetna, her insurance provider. She told the doctor she was asthmatic and that if she didn’t receive treatment, her medical history indicated the infection would settle in her chest.


The doctor refused to help; instead of a prescription, McMurrain got “a lecture on how people use antibiotics too much.” Then she got sicker. The sinus infection moved into her lungs, she missed four days of work, and her husband fell ill as well.


In 2017, Teladoc treated 24 million patients. Ninety-two percent, the company claims, were pleased. Some subscribe to the service directly, but others, like McMurrain, access Teledoc through their health insurance. For providers like Aetna, telemedicine offers cost savings and increased access to care. But some consumers wonder how their insurance companies make sure telemedicine partners provide quality care – and what, if any, accountability measures are in place when they don’t.


At Aetna, Head of Network Product and Telemedicine Strategies David Hildebrand says their Teladoc contract includes “performance guarantees” for hold times, call length, and member satisfaction. He mentions no guarantees regarding standard of care. When it comes to whether physicians have the credentials and experience Teladoc claims, Hildebrand says, “We trust them and contractually they’re obligated.”


This trust has propelled the partnership for seven years. When Aetna chose Teladoc in 2011, the telemedicine provider was one of two on the market. “We found them to be the largest and most experienced at that time,” Hildebrand explains, noting email security practices were also considered.


Today, the American Telemedicine Association says around 200 providers are in operation, but Aetna doesn’t plan to change partners any time soon. While Hildebrand says they “continually look at all available options,” changing providers is difficult for a company of Aetna’s size, especially when long-term vendors become partners.


“Over the years we’ve expanded the offering and the partnership to additional services,” he explains. “We’ve rolled out behavioral health with them. We’ve rolled out dermatology, as well as a caregiver program. And we have the opportunity to partner with them and look at building out new products and services. We look at the data together. We look at the communications to our members together, and try to understand them, and provide information at the right time to them, provide them resources to our customers.”


“We’re really trying to innovate… and look at figuring out where the next evolution of telemedicine will go,” he continues. “And it’s easier to do that when you have an incumbent that is as much invested in supporting your members as you are.”


“We’re happy with the partnership that we have; our customers are happy with it.” he adds. How does he know they’re happy? Teladoc surveys say so.


“We do a follow-up with everybody at 72 hours to see if they’ve gotten better or if they needed to go see another provider,” explains Teladoc CEO Jason Gorevic, specifying that everybody really does mean everybody. “Every consumer gets at least an electronic follow up after 72 hours.” That’s where the 92 percent pleased statistic comes from.


That’s what’s supposed to happen, but in reality, everyone doesn’t receive a survey. McMurrain didn’t. Neither did fellow Aetna customer Kim Guthrie of Olney, Texas, who called Teladoc last month with a urinary tract infection. “The doctor told me within three minutes that she couldn’t treat me,” Guthrie says. “She said I needed to go to my regular doctor.”


After refusing service, Teladoc next refused to issue a refund. “It’s just very frustrating,” Guthrie adds, explaining that, as a teacher, she has a fixed income. “Teladoc makes money either way,” she continues, adding that she thinks “they are screwing people over.”


“Obviously, I can’t respond to an individual case without looking into it, but I’m happy to,” Gorevic responded after being asked about Guthrie and others’ claims.


While patients like Guthrie and McMurrain end up having to pay for both a Teladoc consultation and a visit to their regular doctor, Gorevic says financial savings are one of telemedicine’s big draws. The exact amount charged varies by plan, but he says the typical Teladoc appointment costs insurance companies “about $45. That contrasts to about $120 to $125 for a typical office visit, somewhere in the neighborhood of $175 for an urgent care visit, and north of $1,000 for an emergency room visit.” Overall, Teladoc-funded studies show each call saves providers an average of $472.


While Teladoc does keep Aetna’s costs down, Hildebrand says customers aren’t required to see teledoctors before or instead of their primary care physicians: “We don’t have a benefit plan that says they need to use this service before they do something else. It is set up there [for] convenience, to provide access, and allow them to access the service when they feel it’s most important to them.” He does, however, note telemedicine services are priced “at a lower cost share to try to encourage utilization.”


This holds true industry-wide. Oscar Health customers can access the insurance provider’s Doctor on Call service, which directs to Teladoc and other vendors, for free. UnitedHealthcare works with Doctor on Demand and American Well. UnitedHealthcare Director of Communications Lynne High says, “The total cost of a visit is under $50, with the member’s portion of the cost determined by their benefit design.”


“Consumers throughout their entire lives are shifting to the on demand economy, whether it’s booking travel or shopping for groceries or buying shoes,” Teladoc’s Gorevic says, adding “healthcare fits right in with the rest of the economy. Consumers see this as a more-convenient, more-timely way to get care. It also happens to be a more cost-effective way to get care.”


But no matter how cost-effective care gets, providing it – and addressing people’s health concerns – isn’t as simple as buying milk. Khan Shoieb, head of communications for Oscar Health, says when a customer experiences a problem due to quality of care, employees “direct the member to address their concerns specifically with Teladoc” as opposed to Oscar, stressing that Oscar and Teladoc “are two separate entities.” Hildebrand says Aetna’s contract with Teladoc outlines processes for escalation and issue resolution, but open communication is important, especially from people like McMurrain and Guthrie, who don’t make it into Teladoc’s surveys..


“If there’s a problem,” Hildebrand says, “we would want to know about it and address it right away.”


Original By Terena Bell, Contributor – – Feb. 27, 2018, at 3:41 p.m.

Reposted by Physician Licensing Service

23 Feb 2018

Taking the Telemedicine Leap

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In October 2012, Medicare began rewarding hospitals that provide high-quality care for their patients through the Hospital Value-Based Purchasing (VBP) Program. Under VBP, hospitals are paid for inpatient acute care services based on quality of care — not the volume of services they provide.  To this end, a hospital’s Total Performance Score (TPS) and unplanned readmissions are significantly and inversely related to readmission rates.



These new payment models have driven hospitals to evaluate the variables that might impact the readmissions of their patients. One of the most common discharge locations for hospitalized patients are Skilled Nursing Facilities (SNFs). In some communities, this increased scrutiny has revealed that facilities that are not providing services adequate to prevent readmissions, which results in those facilities no longer being a preferred referral source.




Beginning on October 1, 2018, the SNF VBP Program will begin to reward (or penalize) SNFs for 2017 performance by offering incentive payments for the quality of care they deliver to Medicare patients. In this new environment, SNFs across the nation are now – more than ever — seeking creative ways to utilize telemedicine to distinguish themselves with their hospital partners and deliver a higher level of care to their patients by treating them in place, thereby avoiding hospital transfers.



Telemedicine is growing at a rapid pace, and the number of patients using telehealth services will rise to seven million in 2018, up from less than 350,000 in 2013. Broadly defined, telemedicine is the monitoring, diagnosing and treating of patients from a distance using technology. Recent technological advances, particularly during the past 10 years, have enabled medical providers at many levels to be virtually at the bedside like never before.



Telemedicine has been proven to deliver results across a variety of settings with definitive measurables such as length of stay, readmissions, emergency room visits and improved access to caregivers.  However, to achieve positive results and reap the benefits, consideration should be given to several factors.



Key considerations


As SNFs assess the value of telemedicine at their individual facilities, here are areas they ought to consider before taking the leap:



  • How does this service fit into our overall strategy of patient care? A good telemedicine program can make patients and families more comfortable and confident in the care at the facility level. It is beneficial to take into consideration if this will be used to attract new patients. The program should retain patients at the facility, avoiding costly and uncomfortable ambulance trips and Emergency Department visits. Also, it’s best to determine if the results achieved will be used to maintain preferred provider status. The support given to the nursing staff can result in less stress and turnover. It’s important that the organization articulate the reason for adopting a new service and can support both its installation and usage.


  • How will this integrate with current workflow? As with any new program, an important factor to consider with any telemedicine implementation is how it fits within an existing workflow. Ideal telemedicine solutions should enhance and support the care already being delivered, not create one-off processes that required additional staff time.


  • What is the status of the facility’s wireless internet capability? Facilities will need to ensure that they have enough bandwidth to implement the types of telemedicine services they are considering. This can be as simple as adding some new access points or range extenders as well as if more complex solutions might be required. The wireless capability should be assessed in tandem with the telemedicine service provider.  The equipment proposed by the telemedicine provider can have an important impact on the necessary upgrades.


  • How much additional staff training will the service require? It is important to understand what the training costs are in terms of dollars as well as the time needed for educating staff and attending physicians on how the telemedicine solution will be used. Is the proposed equipment so complex that the nursing team might struggle with engaging the telemedicine physicians?


  • Is there reporting available to measure the results of the service? How can metrics be accessed and communicated to the facility leadership and in what format? Is there a customer service group that works to enable satisfaction and results after the initial launch of the service? Assuring that the telemedicine provider is prepared to measure and meet the SNF administrative needs are critical success factors.



Measuring the Impact



For SNFs moving forward with telemedicine services, they will find the best successes by understanding their baseline data and setting clear objectives for the program.  Important baseline elements to track before and after the service installation are:


  1. The typical length of stay for a patient


  1. Number of patients who return to the hospital each month



  1. The percent of those who leave and who never return


  1. The percent who return after a hospital stay



  1. The facility Resource Utilization Groups (RUG) Rates

Using this information, the facility can derive the impact on lost revenue.  By comparing the results quarterly to baseline data, the return on investment can be clearly demonstrated.




In a recent study by the TRECS Institute (a non-profit organization dedicated to improving care for seniors while decreasing healthcare cost), during which telemedicine physician services were used, both a dramatic improvement in the quality of patient care delivered as well as a significant financial benefit were reported: in many instances of hospital admissions/readmissions were averted. Additionally, results revealed positive increases in net revenue for the study facility, which significantly exceeded the cost of the telemedicine provider’s services, thereby improving both top- and bottom-line financial performance for the SNF.



Mary Jo Gorman, Chief Executive Officer, TripleCare

Physician Licensing Service
February 23, 2018









Implementing a successful telemedicine solution is a smart and affordable way to stay in preferred provider networks, increase facility census, reduce hospital readmissions, make room for happier residents and their families and ensure more confident staff members are part of the team.


Go ahead and take the leap; it may just be what helps you stay afloat amid the changing healthcare waters.



Mary Jo Gorman, M.D, is chief executive officer of TripleCare, a leading high-acuity telemedicine services provider to skilled nursing facilities throughout the U.S. She can be reached at


30 Jan 2018

Enhanced Interstate Nurse Licensure Compact Implemented

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Published on Medscape by Troy Brown, RN – January 25, 2018

Republished by Physician Licensing Service


The National Council of State Boards of Nursing (NCSBN) has added new requirements to the Nurse Licensure Compact, an interstate agreement that allows nurses to practice in multiple states with one license.



The Enhanced Nurse Licensure Compact (eNLC) adds state and federal criminal background checks, restricts licensure for nurses with felony convictions, and standardizes licensure requirements among participating states. The implementation date for the eNLC was January 19, 2018.



“Although these nurses may skip the licensing process in the eNLC states, they still must follow the laws and nurse practice act of each state where a patient is located. The eNLC affects registered nurses and licensed practical or licensed vocational nurses; it does not apply to advanced practice nurses,” healthcare attorney Carolyn Buppert, MSN, JD, writes in an article for Medscape Medical News published November 1, 2017.



Maryland signed the original NLC into law in 2000. It enables registered nurses and licensed practical/vocational nurses licensed in one compact state to practice in other compact states without having to obtain an additional license. Advanced practice nurses are not included in the compact.



Proponents of the compact say it enables nurses to provide direct nursing care and telenursing services to patients located across the United States without having to obtain multiple licenses. The compact also facilitates the movement of nurses across state borders to provide care during disasters and reduces licensing burdens for nurses who live in areas that border two or more states.



The enhanced version adds the requirement of a criminal background check (state and federal) at the time of initial licensure and restricts nurses from obtaining a multistate license if they have ever been convicted of a felony. In addition, the eNLC requires compact states to adopt the NCSBN’s Uniform Licensure Requirements, which “establish consistent standards for initial, endorsement, renewal and reinstatement licensure needed,” according to the American Nurses Association.



“Nurses who had a multistate license as of July 20, 2017, will not need to meet these requirements and will be grandfathered in under whatever requirements they met at the time of their application. However, if they move to another state, they will be subject to the requirements of the eNLC,” Buppert explains.



To date, 29 states have enacted eNLC legislation: Idaho, Montana, North Dakota, South Dakota, Nebraska, Wyoming, Utah, Colorado, Arizona, New Mexico, Texas, Oklahoma, Missouri, Iowa, Arkansas, Wisconsin, Kentucky, Tennessee, Mississippi, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Delaware, Maryland, New Hampshire, and Maine.



eNLC legislation is pending in Vermont, Massachusetts, Michigan, Indiana, Illinois, and New Jersey. That legislation must be signed by the states’ governors after advancing through the states’ legislatures.



Nurses in good standing whose declared primary state of residence is a compact state are eligible to practice nursing in any of the other compact states; however, they are only allowed to have one license. As with drivers’ licenses, nurses who change their state of residence must obtain a new license in the new state and surrender the former multistate license.



Nurses whose primary states of residence are noncompact states are not eligible for a compact license, according to the NCSBN.