relevant to clinicians and managers, efforts to inform and educate patients and consumers.

Added to the uncertainties about the benefits of telemedicine is the important fact that most telemedicine consultations are not covered by Medicare or other third party payers (see Chapter 2 and Chapter 4 for additional discussion). Most of those interviewed by the committee believed this to be a major deterrent to telemedicine use, regardless of whether or not they were advocates of telemedicine or favored a change in payment policies.

Changes in the American health care system are altering the relationships between clinicians, patients, health care institutions, managed care plans, and public and private purchasers of health care. Strategic alliances, joint venture arrangements, and takeovers are changing historic relationships and centers of control over clinical practice. Practitioners and administrators are acutely concerned about protecting their patient base in the face of cost-driven reductions in the use of many services and changes in referral patterns. Advanced telecommunications technologies stand to alter further the relationships between health care organizations and professionals and between the practitioners and their patients. Will there be gatekeepers for telemedicine applications, and if so, who will play that role—clinicians, health plan managers, government officials, or perhaps the technicians who operate and maintain the equipment? For health care professionals accustomed to assigned roles and responsibilities, questions about who performs new and existing tasks in a networked environment may prompt considerable concern.

What may start as a simple way to improve access through telemedicine may end up as a permanent shift in the locus of patient care—locally, regionally, and even nationally. In the short term, this prospect may lead some to seek policy barriers (for example, licensure restrictions) or other limits on telemedicine practice. In the longer term, however, if telemedicine is viewed by managed care plans and integrated health systems as bringing cost and competitive advantages, they will use their leverage with government officials