It was 2007 when John Scott, MD, MSc, realized the power and need for telemedicine.

As a physician specializing in infectious diseases, he was asked to address hepatitis C outbreaks in a small town in Montana, where he soon discovered the community struggled getting adequate care because of its distance from a major healthcare system.

While Scott, the medical director of telehealth at Seattle’s University of Washington Medicine, was accustomed to treating patients in his office face to face, he realized that wasn’t a possibility for many people in this rural part of the country.

People often weren’t being treated because they didn’t have access to a healthcare system complete with specialists and updated technology.

“They were a long ways away from a healthcare provider, and even if they could go, the specialists didn’t have the [necessary] training and expertise,” says Scott, 47. “And so, to me, that just seemed like a real injustice.”

That’s when he began doing research on how to provide care to patients in rural communities, a historically underserved population. Although a quarter of the country’s population lives in rural settings, only about 10 percent of physicians practice in those areas, according to the National Rural Health Association.

Scott has found a way to integrate telemedicine into his everyday practice using the UW’s Project ECHO (Extension for Community Health Outcomes) program, and he’s not the only one incorporating telemedicine into standard care.

Telemedicine is a growing market, according to research firm IHS, which says that telehealth devices and services are expected to grow to $4.5 billion in 2018 with more than seven million users. Last year, more than 15 million people received healthcare through telehealth methods in the U.S., and the numbers increase every day, according to the American Telemedicine Association, a trade organization based in Washington, D.C.

Insurers make their own rules

Blue Cross Blue Shield, the insurance giant based out of Chicago, serves more than 25 million people across the country. BCBS, like many other insurance companies, has been emphasizing the expansion of coverage they offer for telemedicine services.

In December, BCBS of Alabama began reimbursing providers for telemedicine services, aiming to better serve patients who live in the mostly rural state.

Since then, they have been working to expand coverage to other rural areas, particularly in the Pacific Northwest.

Cambia Health Solutions, based in Portland, Oregon, is the parent company of insurance companies providing coverage to nearly two million people across Utah, Oregon, Idaho and Washington. Four of Cambia’s health plans in the region are licensed through Blue Cross Blue Shield.

Before 2015, covering telehealth services wasn’t a high priority for most insurance companies because the demand from providers and patients had yet to develop. An increased push for coverage was apparent at the end of last year, which is when Cambia began covering it.

Currently, about 60 percent of people enrolled in Cambia’s health plans have telehealth coverage, and the rest are slated to have it by 2017 as plans enter their annual renewal cycle, says Brodie Dychinco, Cambia’s general manager of convenient care delivery.

“We view telehealth as a convenience,” Dychinco says. “From a telehealth perspective, we definitely recognize that not everyone lives in a place that has access or they have to drive really long distances for care.”

Dychinco says he sees people using the phone most often to communicate with their providers, but the use of video conferencing is steadily increasing.

Cambia doesn't approach remote healthcare options solely as an insurance provider. The company is also an investor in Carena MD, a telehealth technology company based in Seattle that sells telemedicine platforms to providers throughout the country. They serve about 15 million patients right now, but it could be more if Medicaid and Medicare reimbursed more telehealth services, according to Robert Bernstein, a family physician and the vice president of clinical affairs at Carena.

“A lot of insurers are moving forward and saying ‘Yes, we’ll start covering some of these telemedicine services,'” he says. “But Medicare and Medicaid are slower to move [to cover] those telemedicine visits. I think both are moving in that direction, but it’s still a significant barrier.”

According to a study published in July in The New England Journal of Medicine, 48 state Medicaid programs cover telehealth services, while Medicare lags behind, only reimbursing certain services in clinical facilities with a shortage of healthcare professionals. Medicaid’s expansive coverage is particularly relevant for rural communities since they have high populations of patients insured by them, according to Debbie Harrison, assistant director of public policy at the National Business Group on Health, a nonprofit in Washington, D.C.

In the private sector, 29 states now have telehealth laws that require private insurers to cover telehealth services, double the number of states from just three years ago.

But it gets more complicated since the type of coverage varies from state to state. State governments dictate what telehealth methods can be reimbursed in their state. For example, regulation in Washington explicitly says that email and phone visits cannot be reimbursed. In other states like Idaho and Delaware, they can.

“There’s a lot of hope that telehealth will save costs in the long run,” Harrison says. “If people have access to telemedicine, that can prevent emergency room visits, and it might be better for long-term care for someone who has a chronic condition.”

Getting acquainted with innovation

Telehealth sounds like a great option. It’s easy, convenient and affordable. For minor illnesses and routine visits, it could be a good option for someone who lives 150 miles from the nearest provider. Because of its convenience, even urban dwellers are trying it out. Patients are getting on board, but sometimes it’s the doctors that aren’t. Some are just stuck in a routine, Dychinco says.

Physicians are accustomed to seeing patients face to face, and often times already have back-to-back appointments booked. Changing their normal workflow or finding time in an existing schedule can be challenging for physicians who run their own practice or have clientele who are used to coming in for a visit.

“Doctors are going from room to room in their own office and they’re really busy already,” Dychinco says. “To ask them ‘Hey, in your free time, would you like to see video visits or phone visits?’ Their first answer will be, ‘Well, what free time are you talking about?’”

To help out swamped doctors, some providers are designating specific physicians to exclusively address telehealth visits, while other doctors work like they always have—seeing patients in person.

“I would love the day where it isn’t about the patient sitting in a waiting room hearing the terms ‘The doctor is ready to see you now,’” Dychinco says. “I’d love to shift that to ‘The patient is ready to see the doctor now.’”

Traditional visits will persist

Though telehealth is growing, it has limitations. If a patient is experiencing abdominal pain and needs an examination, they’ll likely have to see a doctor in person. Likewise, musculoskeletal exams also need to be done in person.

“Telemedicine is not good for a patient that is super, super complicated, where you need to do a lot of follow-up imaging or things like that,” Scott says.

He says there have been instances where he had to stop a telehealth session because he realized mid-visit that he actually needed to see the patient in person.

Additionally, physicians are restricted in what medications they are allowed to prescribe via telehealth. Drugs like opioid pain and psychiatric medications are usually prohibited because conditions that need those kinds of medication often require an in-person exam, and physicians want to limit patients’ ability to abuse them since they are highly addictive.

“We really feel like those need a detailed in-person examination over telemedicine,” Scott says. “There’s a potential for harm that we’re just not comfortable with.”

On the flip side, physicians can provide antibiotics, non-opioid pain relievers and other over-the-counter remedies.

Future options

As the director of telehealth at UW Medicine, Scott is constantly looking for ways to expand virtual healthcare. This summer, the health system began offering an eConsultant program that specializes in dermatology, endocrinology and hematology.

They also plan to launch a tele-emergency program this year for patients who don’t have access to trauma centers, a sector of telehealth currently gaining momentum. Mayo Clinic in Rochester, Minnesota, recently expanded its emergency telemedicine program and now offers it in more than 45 hospitals across nine states.

In addition to its tele-emergency program, UW Medicine also plans to implement telestroke and televascular programs.

Beyond that, the university has built physical clinics in more rural parts of the state. UW Medicine is building an obstetrician clinic in Yakima—a town in the center of the state only accessible through a mountain pass. Sometimes physicians travel to the remote clinic from Seattle, but when they can’t, they opt for video conferencing.

“It’s almost like a normal visit,” Scott says. “They come into an exam room and they get seen. The whole idea behind telemedicine is that technology, when it’s really working, goes into the background and you hardly notice it.”