Assessment of Approaches to Evaluating Telemedicine. 3. Perspective of Evaluation


The perspective of evaluation refers to the standpoint from which costs and benefits of a program or intervention are realized. For instance, the perspective of an evaluation of a teleconsultation program may be that of one or more of: society overall, third-party payers (e.g., Medicare, state Medicaid programs, or managed care organizations), a "hub" hospital in a teleconsultation network, referring primary care physicians, consulting physician specialists, patients, and even any funding agency that is supporting the program. Clearly, costs and benefits are not realized in the same way from each of these perspectives. Therefore, the findings of a telemedicine evaluation may be influenced or dictated by the evaluation perspective chosen. Many analysts favor using the broad perspective of society and identifying all costs and all benefits accordingly. However, what is cost effective from the perspective of a national agency (if it is assumed to have a societal perspective) may not be what is cost effective from the standpoint of a hospital manager or a patient.

The success of a teleconsultation program is likely to depend, at least in part, on the incentives and disincentives that prevail from the perspectives of stakeholders in the program. The flow of third-party payment, and therefore an incentive for participating in teleconsultations, is directly influenced by such factors as site of service, whether a physician is a referring or consulting physician, and the way in which a physician is compensated (e.g., based on salary or fee-for-service). For some physicians, such as already over-burdened referral physicians, the prospect of participating in telemedicine encounters (as opposed to simply referring patients to consulting specialists) may pose an increased workload. The time required to become proficient at practicing in a telemedicine environment may be a barrier to participation for some busy physicians. Persuading third-party payers of the cost-effectiveness of telemedicine may require demonstrating that current reimbursement for teleconsultations may diminish downstream adverse health events and utilization of services.

Multiple expert interviewees noted the significance of cost savings to patients and families, and that these savings should be accounted for in policy making pertaining to telemedicine services. Patients incur costs savings primarily as a result of the convenience of telemedicine, e.g., less time taken off work or school and lower costs of travel and accommodations, of particular importance for patients with conditions requiring regular visits, such as psychiatric treatment. Such costs and savings are of greater or lesser importance to a payer, depending on the payer's financial responsibility. For example, while Medicare does not reimburse patients for travel time, virtually all state Medicaid programs do.

Adding to the complexity of identifying the perspectives of a telemedicine evaluation is that a given telemedicine program or network often has multiple applications, such as teleconsultations, continuing education, and administration. Further, it may be used by multiple clinical or administrative departments. Therefore, assessing the net value of a telemedicine program is likely to entail evaluating its costs and benefits for one or more perspectives for these multiple applications. In any case, evaluations of telemedicine should identify and describe its evaluation perspectives.

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