Telemedicine is booming, but it’s also controversial and disconnected from mainstream medicine. Is this an idea that seems hot but proves to be just a big niche, or are we looking at a powerful force for change in healthcare?
The American Telemedicine Association reported 1.25 million visits to DTC providers in 2015. Teladoc, a leading entrepreneurial DTC company, has gone public and several others (American Well, MDLive) are doing well. Many corporations are adding telemedicine to their benefit packages, as are some insurance companies. In the government funded healthcare space, the VA and some state Medicare programs are beginning to use telemedicine. And, telemedicine has long had a role in rural areas and for people at sea.
The new-wave, DTC telemedicine is largely separate from traditional medical providers: essentially it’s virtual urgent care. That works because patients are often looking for quick help or reassurance for common, minor illnesses (sore throat) that occur frequently but not so worrisome. So, in most cases, follow-up care is not be required, or the hand-off the the regular provider is simple: the patient can report on the telemedicine encounter or carry in notes from the visit that the tele-provider gives them. But, this lack of care coordination will inevitably cause errors or re-work in some cases.
Some studies have found that patients with chronic illness who were provided with tracker devices to monitor for signs of deterioration did not do significantly better than patients receiving traditional care, while others have shown better results. The chealthblog, published by the Connected Health Center at Partners Healthcare in Bostonand curated by its director, Dr. Joe Kvedar, provides a useful commentary on studies of connected health. Joe emphasizes that patient monitoring has shown good results when it is integrated into the overall care process and supported with coaching and patient motivation, particularly when the care team shows it is watching the data and responding to it. Otherwise it may well prove unproductive.
Telehealth has received uneven support from insurance companies, state medical boards, and federal health programs. Is this wisdom, caution, or excess conservatism and self-protection? Kaiser Permanente appears to be using telemedicine successfully and VA docs email with their patients and feel it’s a good use of time. That shows telemedicine can work well, and I’m not surprised this validation comes from capitated providers who own the long term economics of caring for their patients and control most of the health system in which they operate. They are in the best position of see how telemedicine can integrate with and leverage other parts of the care system.
Other parts of the healthcare system are resisting telemedicine. Utah and Texas have pushed back hard, allegedly at the behest of the state medical establishment. States vary on permitting out-of-state providers to make tele-visits: another point of friction between the digital world and state-level regulation of medicine. Reimbursement of telemedicine varies by state and is sometimes seen as inadequate. Insurers are said to be concerned that making it easier to reach a doctor will lead to over utilization. But surely there are more intelligent ways to triage patients than making them drive 20 miles and then wait an hour to see a doctor.
Despite this debate, uncertainty, and fragmentation, I think the way forward is clear. Compelling evidence shows that telemedicine does work for a wide range of conditions if the process is structured in a smart way. And the health care system will only get better at utilizing telemedicine. Better software platforms to manage telemedicine and changes to the patient interaction process, e.g. making it more asynchronous, promise improvements. Entrepreneurs and startups are leading the way here.
Second, the economics of telemedicine are compelling for providers. Telemedicine visits tend to be shorter than office visits, so provider time is used more effectively. The overhead required to support telemedicine visits is also less: office space, receptionists, and data collection time. From my work with a primary care provider organization, I’m convinced that about half of primary care visits can be accomplished by telemedicine at about 2x the productivity of office visits. This can go a long way to alleviate the shortage of primary care providers and help hold down the cost of medical care.
Telemedicine also enables providers to discover problems earlier and head them off before they become dangerous, painful, and costly. Patients can more easily enter the triage pipeline with a concern; this will promote early detection of emerging conditions. ER visits can be avoided; one study found that 27% percent of ER visits, costing $1000 and up, could be replaced by a $50 telemedicine visit. And specialist consults can occur more quickly at lower cost. Dermatology is particularly well suited for this: “should I be concerned about this mole?” Entrepreneurs are leveraging cloud/mobile technology cleverly to make this possible: e.g., SkyMD and Miiskin.
Telemedicine will be integrated into core provider practices: primary, specialty, and tertiary. They need it for efficiency, care coordination, and increased visibility into patient status away from the clinic. Entrepreneurs will provide software platforms to enable this, such as OpenTeleHealth.
And telemedicine will happen because patients demand it. Austin Frakt’s article points out that the value of patient time wasted by the medical system is huge. Employers see this and will demand telemedicine as part of their health benefit offering to keep employees healthy, productive, and happy. Millennials do most things on the smartphone. Every other industry is learning how to communicate with them on the device to which they pay attention. Healthcare providers will be dragged into this too, eventually. When a technology drives both big cost savings and customer preference, it’s hard for even doctors to ignore.