¹ Randall, Teri, Rural Health Care Faces Reform Too; Providers Sow Seeds for Better Future, 270 JAMA 419 (1993)CrossRefGoogle ScholarPubMed. Twenty-five percent of the U.S. population lives in rural areas. Id. While the prob lems of rural health care delivery are numerous, solving the shortage of primary care physicians is the key to providing basic care to rural areas. Therefore, this Note will focus on primary care physicians as a surrogate for rural health services generally. See Everett Koop, C., Telemedicine Will Revolutionize Care, USA TODAY, Aug. 23, 1993, at 9A.Google Scholar

² The Congressional Office of Technology Assessment gives examples of mid-level practitioners as nurse practitioners, certified nurse-midwives, physician assistants and certified nurse anesthetists. U.S. Congress, Office of Technology Assessment, OTA-H-434, Health Care in Rural America: Summary 14 (U.S. Government Printing Office, 1990) [hereinafter OTA Summary].

³ 139 Cong. Rec. S76U-02, S7627 (daily ed. June 22, 1993) (statement of Sen. Baucus) (The Rural Health Improvement Act) [hereinafter RHIA]; Lisa Belkin, New Wave in Health Care: Visits by Video, N.Y. TIMES , July 15, 1993, at Al. See generally U.S. Congress, Office of Technology Assessment, OTA-H-434, Health Care in Rural America (U.S. Government Printing Office, 1990) [hereinafter HCRA].

⁴ HCRA, supra note 3, at 6; David Holthaus, Rural America: A Hospital Fights the Economic Odds, 63 HOSP. 42 (1989); Craig Thomas, Reformers: Don't Forget About Rural Care—Neither Pay or Play Nor Managed Care Will Work for Us, Says Wyoming Rep. Thomas, ROLL CALL , July 19, 1993, at 1.

⁵ See Randall, supra note 1, at 419. Generally, the federal government's role in addressing the shortage of medical services, and in particular, general practice physicians, is limited by the scope of federal power. OTA Summary, supra note 2, at 4. However, the federal government does have a role to play in effecting changes in rural America's health care shortages. Id. While changes on a local level specifically adapted to the situation in a particular state or community are better suited to the states themselves, rural primary care shortages affect a significant part of the U.S population in 46 states. Connecticut, Rhode Island, New Jersey and Hawaii did not have any rural primary care shortages in 1988. HCRA, supra note 3, at 297-98. Nearly 44% of state resources for rural health activities come from federal sources without even including enormous federal health insurance programs like Medicare and Medicaid. Id. Therefore, the federal government is in the best position to discover information and furnish it to the states and communities so the states can make decisions that address their specific rural health needs. OTA Summary, supra note 2, at 4.

⁶ HCRA, supra note 3, at 296. The National Health Scholar Corps program is an example of this approach. See infra notes 99-131 and accompanying text.

⁷ Id. at 293.

⁸ Randall, supra note 1, at 419.

⁹ See Koop, supra note 1, at 9A.

¹⁰ See id.; Belkin, supra note 3, at A1; Smothers, Ronald, 150 Miles Away, the Doctor Is Examining Your Tonsils, N.Y. TIMES, Sept. 16, 1992, at C14Google Scholar. The term telemedicine describes the use of telecommunications technology to enhance the delivery of medical services. OKLAHOMA ACADEMY FOR STATE GOALS , TELEMEDICINE : TELECOMMUNICATIONS PLUS CLINICAL MEDICINE 1 (1992) (on file with the author) [hereinafter Oklahoma], “‘Telemedicine’ means an interactive telecommunications system that utilizes audio, video, and other appropriate elements and is compatible with other telemedicine networks and that is used for the purpose of enhancing the delivery of medical care .. ..” GA . CODE ANN. § 50-5-192 (1994).

¹¹ Preston, Jane et al., Using Telemedicine to Improve Health Care in Distant Areas, 43 HOSP. & COMMUNITY PSYCHIATRY 25,25 (1992)Google ScholarPubMed.

¹² Id. TEXAS TECH UNIV . HEALTH SCI . CENTER , THE TEXAS TECH MEDNET DEMONSTRATION PROJECT , EXECUTIVE SUMMARY 1.102 (1992) (on file with the author) [hereinafter Texas].

¹³ Throughout this Note, the term “local physician” is used to describe a physician who is physically with the patient and “consulting physician” is used to describe the physician who is at a remote location— typically an urban hospital.

¹⁴ HCRA, supra note 3, at 293.

¹⁵ Oklahoma, supra note 10, at 1.

¹⁶ Texas, supra note 12, at 1.102.

¹⁷ Preston, supra note 11, at 25.

¹⁸ Texas, supra note 12, at 1.102.

¹⁹ Id.

²⁰ Id.

²¹ See CENTER FOR HEALTH POLICY RESEARCH , ANALYSIS OF EXPANSION OF ACCESS TO CARE THROUGH USE OF TELEMEDICINE AND MOBILE HEALTH SERVICES , REPORT TWO : CASE STUDIES AND CURRENT STATUS OF TELE-MEDICINE 22 (1994) [hereinafter CHPR2].

²² See id.

²³ The Health Sciences Center in Lubbock, Texas provides two weekly CME programs via satellite uplink with one-way video and two-way audio. Preston, supra note 11, at 29. This type of system could also potentially serve a patient directly, if set up to transmit from rural areas to urban areas. However, the one-way nature of the transmission makes phone or fax follow-up necessary, and therefore seems inefficient for patient diagnosis or examination.

²⁴ See, e.g., CHPR2, supra note 21, at 16, 20, 22.

²⁵ See Randall, supra note 1, at 419 (regarding rural physician attitudes).

²⁶ Smothers, supra note 10, at C14; Andy Miller, Medicine's Video Age: New Technology Expected to Help Rural Hospitals, Reduce Patient Costs, ATLANTA J. & CONST. , Apr. 6, 1993, at El.

²⁷ See Smothers, supra note 10, at C14. The following are descriptions of these instruments: stethoscope, an instrument used to detect and study sounds produced in the body; othoscope, an instrument used for examining the drum membrane or listening to sounds in the ear; endoscope, an instrument for the examination of the interior of a hollow organ or canal; microscope, an instrument that gives an enlarged image of an object or substance; electrocardiogram (EKG), the graphic record of the changes of electrical potential occurring during the heartbeat (used especially in diagnosing abnormalities of heart action); echo-cardiogram, a visual record by the use of ultrasound to examine the structure and functioning of the heart for abnormalities and disease; sonogram, an image produced by ultrasound.

²⁸ Miller, supra note 26, at El.

²⁹ Id.

³⁰ Id. Cameras on examination instruments can ‘“focus on a hair follicle, see the blood vessel in the eye, truly as well as the physician in the office’ who is checking the patient at a [remote site].” Id. (quoting Dr. Francis Tedesco, president of the Medical College of Georgia).

³¹ Id.

³² Smothers, supra note 10, at CI4; Barbara Harrison, Is There A Doctor on The Screen?—The Use of Telemedicine in Remote Communities Is Only Now Being Fully Explored, FIN . TIMES , June 29, 1993, at 11. The MCG is working with the Georgia Institute of Technology to develop an electronic glove that will simulate the sensation of physical examination. The local physicians would examine a patient wearing a glove and the consulting physician would “feel” the exam by putting his hand on a sensory generator. Theoretically, the sensory generator would be capable of transmitting the force, texture and temperature of the local physician's examination. Id.; CHPR2, supra note 21, at 11.

³³ See CHPR2, supra note 21, at 11.

³⁴ Smothers, supra note 10, at C14.

³⁵ See CHPR2, supra note 21, at 12. The Medical College of Georgia has established a program that allows rural area physicians to obtain Category 1 CME credit for consultations using telemedicine. Id.

³⁶ The remainder of this Note will assume a two-way interactive video and audio system unless otherwise noted.

³⁷ Smothers, supra note 10, at C14.

³⁸ Id.

³⁹ Preston, supra note 11, at 26.

⁴⁰ Id.

⁴¹ Id.

⁴² Id. at 26. Analog signals are transmitted in the form of waves while digital transmissions are transmitted in the form of a digital bit-stream of ones and zeros. Id.

⁴³ Id.

⁴⁴ Smothers, supra note 10, at C14.

⁴⁵ Preston, supra note 11, at 26.

⁴⁶ Id.

⁴⁷ Id.

⁴⁸ Id.

⁴⁹ Information infrastructure refers to phone lines, microwave or satellite capability. Some rural communities have few phone lines, making phone line transmission difficult. See Telemedicine: Significant Barriers Remain in Rural Areas, Symposium Hears, Health Care Daily (BNA) (Oct. 25, 1993) [hereinafter Significant Barriers].

⁵⁰ Preston, supra note 11, at 26. The cost of satellite transmission would theoretically decrease as more satellites were put into orbit. Id.

⁵¹ See Significant Barriers, supra note 49. As an example of the problem, the chief medical officer of an Indian Health Service in South Dakota explains that the problem facing her area is that “the unemployment rate is 75 percent for reservations within [my] area and the resulting poverty translates into very few phone lines.” Id.

⁵² CONG. REC. E3114 (daily ed. Nov. 22, 1993) (statement of Rep. Markey) [hereinafter Markey]. Standard telephone lines reduce the clarity of images and result in unacceptably low accuracy. Preston, supra note 11, at 26. Telephone companies are installing lines capable of accurate image transmission as part of the expansion of teleconferencing and the information superhighway, however, rural areas are not necessarily high on the priority list.

⁵³ As previously stated, this Note will concentrate on the primary care physician shortage in rural America as the leading indicator of inadequate access to medical services.

⁵⁴ ld. HPSA is an area designated by the Secretary of Health and Human Services indicating where there is an inadequate number of health care providers. For a discussion of HPSAs see supra notes 93-98 and accompanying text.

⁵⁵ Id. at 293 (using a threshold resident to physician ratio of 3,500:1).

⁵⁶ See Fuchs, Victor R., THE HEALTH ECONOMY 68 (1986)Google Scholar.

⁵⁷ Detsky, allan S., THE ECONOMIC FOUNDATIONS OF NATIONAL HEALTH POLICY 35-36 (1978)Google Scholar. To isolate the emotional component of health care policy decision-making that results in irrationality, Detsky uses the familiar caution to physicians not to treat themselves. Presumably, there is no cost consideration and no lack of information, but the emotional irrationality of illness remains making self-treatment dangerous. Id. at 36, n.b.

⁵⁸ FUCHS, supra note 56, at 67, 77-78, 343-44.

⁵⁹ Tedrick, Susan, Legal Issues in Physician Self-Referral and Other Health Care Business Relationships, 13 J. LEGAL MED. 521, 525 (1992)CrossRefGoogle ScholarPubMed; see DETSKY, supra note 57, at 35.

⁶⁰ FUCHS , supra note 56, at 78, 343-44; see DETSKY , supra note 57, at 34-35.

⁶¹ DETSKY, supra note 57, at 38.

⁶² Id. at 38-39.

⁶³ FUCHS, supra note 56, at 69, 146; see generally Rice, Thomas, Physician-Induced Demand for Medical Care: New Evidence from the Medicare Program, in ADVANCES IN HEALTH ECONOMICS AND HEALTH SCIENCES RESEARCH (A RESEARCH ANNUAL ) 129, 129-30, 156 (Scheffler, Richard M. ed., 1984)Google Scholar; DETSKY , supra note 57, at 38-39. Contra Roger Feldman & Frank Sloan, Competition Among Physicians, Revisited, in COMPETITION IN THE HEALTH CARE SECTOR : TEN YEARS LATER 17, 18, 36 (Warren Greenberg ed., 1988). This Note will assume that the demand curve in health care is supply induced. There is some dispute as to whether demand is truly supply-induced but numerous studies have shown a demand curve that has the characteristics of a supply-induced curve. Rice, supra, at 130. The exact causes of this phenomenon may not be resolved for some time. Id. In any case, the differences found in the demand curve in rural health economies should have the same effects on the demand curve whether it is supplier-induced or not.

⁶⁴ DETSKY , supra note 57, at 38-41. The physician's code of ethics attempts to relieve the tension caused by the conflict of interest between the patient's health and the financial reward to the physician. Id. at 39-41.

⁶⁵ Id. at 39; see generally Abel-Smith, Brian, Minimum Adequate Levels of Personal Health Care: History and Justification, in ECONOMICS AND HEALTH CARE 509 (McKinlay, John B. ed., 1981)Google Scholar. This Note assumes a system where cost-benefit analysis has not been thrust on the physician in the form of HMOs and utilization review.

⁶⁶ Sorkin, Alan L., HEALTH ECONOMICS 23 (1975)Google Scholar.

⁶⁷ DETSKY, supra note 57, at 39.

⁶⁸ For a discussion of the effect of demand shift on price and quantity, see generally, FUCHS , supra note 56, at 126-32.

⁶⁹ See DETSKY, supra note 57, at 38-39.

⁷⁰ Annas, George J. & Miller, Frances H., The Empire of Death: How Culture and Economics Affect Informed Consent in the U.S., the U.K., and Japan, 20 AM. J.L. & MED. 357, 382, fig. 1 (1994)Google ScholarPubMed.

⁷¹ See id. at 381.

⁷² Id. at 382, fig. 1.

⁷³ See Abel-Smith, supra note 65, at 521.

⁷⁴ HCRA, supra note 3, at 287-96.

⁷⁵ Id. Within the HPSA designation, rational areas of delivery need not conform to political boundaries within a state and may even extend across state borders. See 42 U.S.C. § 254 e(a)(1)(1995).

⁷⁶ See SORKIN , supra note 66, at 25 (noting that financial resources of the patient is a fundamental factor impacting demand for health care).

⁷⁷ HEALTH IN RURAL NORTH AMERICA : THE GEOGRAPHY OF HEALTH CARE SERVICES AND DELIVERY 9-10 (Wilbert M. Gesler & Thomas C. Ricketts eds., 1992) [hereinafter HEALTH IN RURAL NORTH AMERICA ]. AS an example, rural per capita income in 1984 was only 71% of urban income or $10,000 compared to $14,000. Id. at 10.

⁷⁸ Id. at 11.

⁷⁹ Id. In 1985, 13.8% of urban residents fell below the federal poverty level, and 18.3% of the rural population did. Id.

⁸⁰ OTA Summary, supra note 2, at 2-3. There is a discrepancy even among persons below the poverty level, with only 35.5% of the rural poor covered by Medicaid compared with 44.4% among the urban poor. Id.

⁸¹ See FUCHS, supra note 56, at 68.

⁸² DETSKY, supra note 57, at 36-37 (discussing demand versus need); cf. Abel-Smith, supra note 65, at 521.

⁸³ See Reinhardt, Uwe E., Reforming the Health Care System: The Universal Dilemma, 20 AM. J.L. & MED. 21, 33 (1993)Google Scholar.

⁸⁴ See id. The ethical perception of necessity is at odds here with economic efficiency and the ability of rural markets to supply an urban quantity.

⁸⁵ Gordon, Rena J. et al., Accounting for Shortages of Rural Physicians: Push and Pull Factors, in HEALTH IN RURAL NORTH AMERICA : THE GEOGRAPHY OF HEALTH CARE SERVICES AND DELIVERY 153, 153, 158 (Gesler, Wilbert M. & Ricketts, Thomas C. eds., 1992)Google Scholar.

⁸⁶ Id. See FUCHS , supra note 56, at 70,97-100 (noting higher prices for services as one factor affecting physician location decisions).

⁸⁷ Gordon, supra note 85, at 161. For example, physicians perceive positions at academic medical centers as prestigious. Id. See also FUCHS , supra note 56, at 70, 97-99 (noting that proximity to medical schools affects physician location decisions).

⁸⁸ Gordon, supra note 85, at 169.

⁸⁹ Id.

⁹⁰ See id.

⁹¹ See supra notes 72-73 and accompanying text regarding adequate quantity.

⁹² The dollar value of reduced demand may be somewhat quantifiable inasmuch as population densities, levels of income, and insurance are known. See DETSKY, supra note 57, at 70. However, the dollar value of reduced supply determinants is more difficult to quantify, because it is typically related to the personal preferences of individual physicians and of physicians as a class. See FUCHS , supra note 56, at 70. Consequently, the remedies for the differences in demand may be easier to determine and legislate than those designed to offset the further reduced quantity created by reduced supply.

⁹³ See 42 U.S.C. § 254e (1995). The previous term Health Manpower Shortage Area was revised to Health Professional Shortage Area in the Senate amendments adopted by the conference committee in the National Health Service Corps Revitalization Amendments of 1990. Pub. L. No. 101-597, U.S.C.C.A.N. (101 Stat.) 4287,4317 (conference committee report).

⁹⁴ HCRA, supra note 3, at 287-89.

⁹⁵ Id. at 293.

⁹⁶ Id.

⁹⁷ Id. at 295. Significantly, the largest decrease took place before 1985, with a decreasing rate after that. There was only a .5 % decrease between 1985 and 1988. It is important to note that funding for some programs decreased during this period. However, this prior rate of decrease was insufficient to alleviate the problem in the predicted time.

⁹⁸ OTA Summary, supra note 2, at 14, tbl. 2.

⁹⁹ The National Health Service Corps Revitalization Amendments of 1990, Pub. L. No. 101-597, U.S.C.C.A.N. (101 Stat.) 4287, 4316 (House Report) [hereinafter House Report].

¹⁰⁰ Besides the NHSC program, there are three other types of programs that represent the federal efforts in this area. OTA Summary, supra note 2, at 4. The first type of program consists of federal health care financing programs such as Medicare and Medicaid. The second type of federal program is the health block grant, which allocates funds directly to states who use the funds for programs in a specific area. The third type of program enhances knowledge of rural health problems by initiating, funding, and coordinating research. The two major agencies in the Department of Health and Human Services involved in this type of program are the Office of Rural Health Policy (OHRP) and the Agency for Health Care Policy and Research. Id.

¹⁰¹ See Medicare Payments for Graduate Medical Education: Hearing Before the Subcommittee on Medicare and Long-Term Care of the Senate Committee on Finance, 102d Cong., 2d Sess. 90-92 (1992) (statement of William Toby, Jr., Acting Administrator, HCFA). At the senate subcommittee hearing addressing primary care physician shortages, the acting administrator of HCFA outlined five programs administered by HCFA and four programs under the Public Health Service (PHS). Of these nine programs, eight involved subsidies, loan repayment or monetary incentives to physicians and facilities. Id. The ninth program was a cost-cutting program which assigned a primary care physician to each Medicaid recipient to refer the patient for other care as needed in much the same way as a health maintenance organization (HMO). Id.

¹⁰² House Report, supra note 99, at 4288 (Purpose and Summary of NHSC amendments).

¹⁰³ Id. There is also a volunteer program. Id.

¹⁰⁴ Id. at 4289.

¹⁰⁵ Id. at 4288.

¹⁰⁶ Id. at 4290.

¹⁰⁷ Id.

¹⁰⁸ Id. at 4289.

¹⁰⁹ Id. at 4290.

¹¹⁰ Id. at 4289. There was 26% minority participation and only a four percent default rate. Id. While both of these results are reason to applaud the program, they are not the proper measures of the NHSC program's success regarding its primary mission: to supply physicians to underserved areas.

¹¹¹ Id. at 4316.

¹¹² Id. at 4289.

¹¹³ Id. at 4288.

¹¹⁴ Id. at 4290.

¹¹⁵ See infra note 126-29 and accompanying text.

¹¹⁶ House Report, supra note 99, at 4290.

¹¹⁷ Id.

¹¹⁸ Id.

¹¹⁹ FUCHS , supra note 56, at 135-36.

¹²⁰ House Report, supra note 99, at 4290.

¹²¹ See infra section II.B.

¹²² Addressing the problem with demand subsidies alone necessarily means increasing rural demand above urban demand which is politically unpopular. See infra note 129 and fig. 5 and accompanying text.

¹²³ See supra notes 72-73 and accompanying text.

¹²⁴ House Report, supra note 99, at 4290.

¹²⁵ FUCHS , supra note 56, at 135-36.

¹²⁶ SORKIN , supra note 66, at 25 (citing a patient's financial resources as a fundamental factor impacting demand for health care).

¹²⁷ Cf. Rapoport, John ET AL. , UNDERSTANDING HEALTH ECONOMICS 114 (1982)Google Scholar. Federal subsidization allows rural areas to buy more services with the same out-of-pocket expense, thus, in effect, reducing the out-of-pocket expense of receiving the higher quantity of services. Id.

¹²⁸ The House Report calls upon states to tie larger amounts of medical education funding to rural service obligations. In calling on the states to shoulder more responsibility, the House Report went so far as to specifically list the amounts that five large states spend on medical education and the percentage of that funding that was tied to post-graduation rural service obligations compared to the number of underserved citizens in each state. House Report, supra note 99, at 4291.

¹²⁹ If anything, federal funding for rural health care programs is likely to be reduced. National Rural Health Association, NRHA Opposes U.S. House of Representatives Move to Gut Funding for Rural Health Programs 1 (March 7, 1995) (press release, on file with author).

¹³⁰ FUCHS , supra note 56, at 70. Receiving higher prices for their services is only one of the factors that affect a physicians' locational decisions. They are also attracted by medical schools, hospital beds, and by the level of educational, cultural, and recreational opportunities available. Id. at 70,97-99.

¹³¹ SENATE SUBCOMM. ON MEDICARE AND LONG -TERM CARE OF THE SENATE COMM. ON FINANCE , Hearings on Medicare Payments for Graduate Medical Education, 102d Cong., 2d Sess. 57-58 (1992) (statement of J. Robert Buchanan, Chairman, American Medical Colleges and general director, Mass. Gen. Hosp.) [hereinafter Buchanan Statement].

¹³² FUCHS , supra note 56, at 70, 97-99.

¹³³ See 139 CONG . REC. S7090-02 (daily ed. June 10, 1993) (statement of Sen. Harkin) [hereinafter Harkin]; RHIA, supra note 3, at S7627; Smothers, supra note 10, at C14; Pushkin, Dena S., Telecommunications in Rural America: Opportunities and Ghallenges for the Health Care System, Address Before the New York Academy of Sciences, 670 Annals N.Y. Acad. Sci. 67 (1992).CrossRefGoogle Scholar

¹³⁴ Smothers, supra note 10, at C14.

¹³⁵ Preston, supra note 11, at 27; Smothers, supra note 10, at C14.

¹³⁶ Pushkin, supra note 133, at 68; Preston, supra note 11, at 27.

¹³⁷ Preston, supra note 11, at 27; Smothers, supra note 10, at C14.

¹³⁸ See Markey, supra note 52, at E3114; Preston, supra note 11, at 27.

¹³⁹ See Telemedicine: More Research Needed Before Medicare Can Reimburse Service, Report States, Health Care Daily (BNA) Dec. 28, 1993; Preston, supra note 11, at 30; Georgia Project First to Receive Medicare, Medicaid Reimbursement, Health Care Daily (BNA) (Aug. 13, 1993) [hereinafter Georgia Project]; Miller, supra note 26, at El.

¹⁴⁰ CHPR2, supra note 21, at 24.

¹⁴¹ Id.

¹⁴² Id.

¹⁴³ Id. at 26.

¹⁴⁴ Id.

¹⁴⁵ Sometimes impressions are misinterpreted in an initial examination done through telemedicine. Id.

¹⁴⁶ See Koop, supra note 1, at 9A.

¹⁴⁷ Pushkin, supra note 133, at 68.

¹⁴⁸ Belkin, supra note 3, at Al; Georgia Project, supra note 139.

¹⁴⁹ See Belkin, supra note 3, at Al.

¹⁵⁰ Randall, supra note 1, at 419.

¹⁵¹ See Buchanan Statement, supra note 131, at 58-59.

¹⁵² See SENATE SUBCOMM. ON MEDICARE AND LONG -TERM CARE OF THE SENATE COMM. ON FINANCE , Hearings on Medicare Payments for Graduate Medical Education, 102d Cong., 2d Sess. 14-16 (1992) (statement of Hon. C. Everett Koop, former Surgeon General, U.S.) [hereinafter Koop Statement].

¹⁵³ Buchanan Statement, supra note 131, at 58.

¹⁵⁴ Miller, supra note 26, at El. But see Koop, supra note 1, at 9A.

¹⁵⁵ See Experts Discuss ‘Pachysandra Effect’ of Virtual Reality at IEEE Media Briefing, PR NEWSWIRE (PR Newswire Ass'n) (Oct. 20, 1993) (predicting that “[i]n operating rooms of the future, virtual reality will allow physicians to work in different places at the same time”).

¹⁵⁶ CHPR2, supra note 21, at 25.

¹⁵⁷ Koop, supra note 1, at 9A.

¹⁵⁸ Oklahoma, supra note 10, at 3.

¹⁵⁹ ld.

¹⁶⁰ Id.

¹⁶¹ Smothers, supra note 10, at C14.

¹⁶² Oklahoma, supra note 10, at 2.

¹⁶³ See Smothers, supra note 10, at C14.

¹⁶⁴ Id.

¹⁶⁵ See id.

¹⁶⁶ See, id.

¹⁶⁷ Montana, Oklahoma and Pennsylvania all launched programs during 1993.

¹⁶⁸ See Smothers, supra note 10, at C14; Telemedicine: More Research Needed Before Medicare Can Reimburse Service, Report States, supra note 139. For a discussion of HCFA concerns about reimbursement for telemedicine, see infra notes 173-74 and accompanying text.

¹⁶⁹ Id.

¹⁷⁰ Smothers, supra note 10, at C14.

¹⁷¹ Georgia Project, supra note 139.

¹⁷² See Smothers, supra note 10, at C14.

¹⁷³ Georgia Project, supra note 139.

¹⁷⁴ Id.

¹⁷⁵ Reinhardt, supra note 83, at 33.

¹⁷⁶ Georgia Project, supra note 139.