For UPMC surgeon Andrew Watson, it was a no-brainer.
It was February 2009, and he had been practicing laparoscopy for 2 1/2 years at UPMC, always meeting his patients in person in his office for pre- or post-operative consultations and checkups.
But fellow surgeon David Faber of Bedford, Bedford County, proposed that Dr. Watson try using telemedicine to meet with some of the patients Dr. Faber referred to him -- some of whom would drive three or more hours from central Pennsylvania to Dr. Watson's Downtown office.
UPMC Bedford Memorial Hospital already had a year-old video link to Pittsburgh for UPMC's telestroke system -- in which experts in Pittsburgh consult on the use of blood thinners for potential stroke patients in Bedford.
"I'd worked with technology during my entire career, so, when I heard about the opportunity to use telemedicine this way, it seemed like a natural fit," said Dr. Watson, who has had 65 telemedicine visits in the 18 months since then.
For Dr. Faber, it has worked out better than he hoped.
"I needed better access to him and the resources in Pittsburgh, and my patients didn't want to make that two-plus-hour drive every time," Dr. Faber said.
Now, even though their offices are more than 100 miles apart, Dr. Faber said of Dr. Watson: "I consider him to be just down the hall from me."
They are only the latest converts to the system at UPMC. Starting with the use of video conferencing to do psychiatry in prisons 13 years ago, UPMC has expanded its use of telemedicine. With video conferencing, in-home monitoring of congestive heart failure patients, or e-mailing radiology exams from site to site, UPMC now has 15 different hospitals using telemedicine in 13 different fields, including cardiology, pathology, dermatology and ophthalmology.
Telemedicine should save health care dollars, advocates said, because some patients won't have to drive as far to see doctors and some monitoring can be done in their homes without a nurse's visit. It also can improve health care, they said, by providing patients with access to specialists they might not see otherwise.
Telemedicine isn't being used everywhere in Pennsylvania, though.
Beyond UPMC, and a few scattered programs at hospitals around the state, very little telemedicine -- or telehealth as it's sometimes called -- is being practiced in Pennsylvania.
That's despite the push made by Gov. Ed Rendell and other advocates in the state, and despite the fact that it's being trumpeted nationwide by President Obama as a potential cost-saver and health-improver, thanks to the increased quality of technology and the decreased cost of equipment that could bring better care to people who might not otherwise get it.
"We believe in creating the opportunity for telemedicine to expand," said Aneesh Chopra, President Obama's chief technology officer.
So, why hasn't it expanded more rapidly here in a state that has received plaudits in recent years for being on the forefront of medical advances in technology and the containment of hospital-acquired infections?
"Reimbursement has so much to do with this," said Joseph Tracy, vice president for telehealth services for the Lehigh Valley Health Network in Bethlehem, which has perhaps the second most expansive telemedicine system in the state after UPMC.
"It won't expand faster unless we figure out the reimbursement."
In short, most hospitals in Pennsylvania say they aren't using it because most insurers aren't paying for it. The private insurers and state Medicaid officials say they aren't paying for it because they aren't sure yet if it is effective and because Medicare -- which often leads the way on such payment issues, setting national standards -- still isn't paying for it either, except in very limited rural areas. And Medicare officials said they can't expand reimbursement of telemedicine without Congressional approval of a new law.
On top of that, Congress isn't in a big rush to approve a change in the 1997 law that currently guides Medicare's telemedicine payments. That's because it was recently shot down for inclusion in the health care reform law after a Congressional Budget Office estimate said expanding telemedicine coverage to all Medicare patients would cost hundreds of millions of dollars. Medicare paid only $2.6 million for telemedicine-related charges for all of 2009.
"If Medicare expands telemedicine beyond the rural areas, it will make for a sea change in reimbursement," said Jonathan Linkous, CEO of the American Telemedicine Association, a 17-year-old advocacy group founded by physicians as a resource and lobbying group for the technology.
"If Medicare approved it, I think that it would pretty much go nationwide and within a couple of years we'd have uniform coverage."
But a dozen states aren't waiting on Medicare.
Those states -- California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon, Texas and Virginia -- all have approved laws over the past 15 years, some stronger than others, requiring private insurers in the state to reimburse for telemedicine charges.
"We figured if Medicare can pay for telemedicine and Medicaid can, why shouldn't private insurers?" said Karen Rheuban, medical director of telemedicine for the University of Virginia Health System, which pushed for approval of their law earlier this year.
For two years a similar law has been proposed in the Pennsylvania House of Representatives. But it still hasn't been brought to a vote in the insurance committee.
Rep. Anthony DeLuca, a Penn Hills Democrat who chairs the committee, said he has held the bill because the private insurers -- led by the four Blue Cross-Blue Shield companies and the Insurance Federation of Pennsylvania -- lobbied heavily to prevent it from moving forward. He believes he could get it out of committee and maybe approved in the House, but, "it won't go anywhere in the Senate" because of the industry's influence and concerns about cost.
The insurance companies and their lobbyists "sent out e-mails and stuff pertaining to the cost factors, and saying it's not proven that it will help, though they didn't cite any studies; they always just cite their opinion," said Mr. DeLuca, who hopes to move it forward next session.
"They have no vision. They only see what it costs them today and can't see how it will save them over the long term."
Sam Marshall, president of the Insurance Federation of Pennsylvania, which represents most of the private insurance companies in the state that are not Blue Cross-Blue Shield, said: "Our big concern is over-utilization."
The insurance industry worries that using telemedicine may add costs by encouraging more visits between doctors and patients and opening up new avenues of potential fraud, instead of simply changing the way patients visit with doctors as advocates contend.
"If someone bills for an office visit, was he really there?" Mr. Marshall said. "If you make it real easy, there's a real tendency that people will use it a lot."
Virginia Calega, medical director and vice president of medical management and policy for Highmark, said the company is going to be doing pilot programs to study "whether it adds value to us and our insurers" to cover telemedicine costs.
Mr. Linkous said any insurer that said it is still studying telemedicine's effectiveness "is pushing the snooze alarm; it's a delaying tactic that says they won't be doing this for five to 10 years. They just don't want to pay for this -- even though we think it will save them money, and study after study shows it will."
In addition to the state laws, 25 state Medicaid plans -- including Pennsylvania's -- currently pay for some forms of telemedicine.
But the Pennsylvania Medicaid plan pays for the use of telemedicine in only two specific programs implemented three years ago: high-risk prenatal care and psychiatry.
David Kelly, medical director for Pennsylvania's Medicaid program, said, however, there has been little use of either program and: "Quite honestly we're scratching ours heads as to why."
Mr. Tracy said he and other hospital officials knew the programs wouldn't be used when they were proposed because the patients must have their referring physician present with them for the telemedicine visit with the psychiatrist or the obstetrics and gynecologist physician.
"Well, then what do you do with [the physicians'] busy practices while they're sitting in on these sessions?" Mr. Tracy said. "Even Medicare doesn't require that."
Pennsylvania's Medicare program also officially still encourages face-to-face visits between doctor and patient, Dr. Kelly said, "because we still have some concern about the quality of care of non-face-to-face visits."
During a recent telemedicine visit between Dr. Watson and some of his Bedford patients, some of those concerns were apparent, too, but they quickly faded away for first-time telemedicine users.
"This is really different," said Claudia Beightol, 49, who looked a bit nervous as she entered the room in Bedford Memorial Hospital with a nurse at her side, and then looked up to see Dr. Watson smiling on a big television screen from his office in the U.S. Steel building in Pittsburgh.
As part of his effort to put a patient at ease, Dr. Watson said he decided he still needed to wear his white lab coat, even though he wasn't in the same room, because "the patients expect it." He also initially had to work to make sure he maintained constant eye contact on the video screen -- as if the person was in the room with him -- rather than letting himself drift away as if watching a television.
Ms. Beightol, a Walmart clerk in Bedford, had serious issues to discuss. She was visiting with Dr. Watson for the first time via video to discuss her Crohn's disease, an inflammatory intestinal disease, that had caused her to lose about 10 pounds in recent months.
After about a 20-minute conversation, Dr. Watson said he'd need more tests to confirm what was happening before they meet again. By then, despite her situation, Ms. Beightol seemed much more at ease.
"I was a little nervous at first," she confessed to Dr. Watson. "But we could go ahead and [have an appointment] like this again. That would be fine. It already saved me taking a day off work to make that drive."
Sean D. Hamill: firstname.lastname@example.org or 412-263-2579.