Telemedicine could be great, if people stopped using it like Uber
These days, more people are working from home, shopping from home, and yes, even seeing the doctor from home. Last year more than a million people traded the waiting room for the comfort of their own couch—which sure beats thumbing through a sad collection of creased magazines.
Today, telehealth is touted as one of the chief ways to deal with rural residents left behind by hospital consolidation, as well as the 20 million new patients the Affordable Care Act brought into the health care system. Its value hinges on the premise that patients will use telehealth options instead of going to the doctor or the urgent care clinic. But a new study released today shows that people are using phone-a-physician services in addition to in-person visits, not as a substitute. And the result of the Uber-ization of health care is an increase in overall costs.
In April 2012, CalPERS Blue Shield started covering telehealth visits for their 300,000 insurance enrollees. Over the next year and half, 2,943 of them came down with a respiratory infection. Two-thirds of those cough-stricken Californians went straight to the doctor. The other third picked up the phone first, using the newly covered direct-to-consumer service offered by a telehealth company called Teladoc.
This seemed like good news—using Teladoc brought down the cost of the average bronchitis episode because patients avoided unnecessary testing and imaging. But when researchers at RAND, a public policy thinktank, looked at whether those calls replaced in-person visits over those 18 months, they found that happened less than 12 percent of the time. In the long-term, spending actually went up $45 per Teladoc patient. They weren’t going to the doctor any less frequently. “If you make something easier to access, people will use it,” said Lori Uscher-Pines, one of the authors of RAND’s paper, published today in Health Affairs. “That lower threshold means that people are using this as an add-on service.”
Patients who use telehealth on top of their normal health care visits add strain to an already overburdened health care system. RAND found that patients who used Teladoc tended to be younger, healthier, tech-savvy city dwellers—not the rural and elderly populations the technology is supposed to be targeting. And because the service takes place outside of the normal health care flow, the physicians on the other end of the line don’t usually have access to each patient’s health records, and the visit may not make it into the patient’s history. Health care experts call this “fragmentation.”
“Telehealth has to be integrated fully into a total care system,” says Mario Gutierrez, executive director of the Center for Connected Health Policy. “It can’t just be a one-off. That’s not health care.” He’d like to see telehealth move away from the convenience economy model where you only dial up when you’re feeling down and out. Instead, he sees a huge opportunity to use it to manage chronic disease and engage people in preventive care. That means embracing telehealth as an essential service, not an add-on.
A few institutions have a jump on this. The US Veterans Administration has reduced hospital admissions by 20 percent and costs per patient by $1,600 each year with its telehealth program. In the world of private health care, Kaiser Permanente leads the pack; last year more than half of its 110 million patient interactions happened online or over the phone.
When patients call or set up a video consultation through Kaiser’s web portal, they get a few options. They can schedule a call or appointment with their primary physician (which could take a day or could take weeks), or they can talk to an on-call emergency room physician right away. If they choose that option, they might get Dennis Truong on the other end, an ER doc who also leads Kaiser’s telemedicine and mobility efforts in the mid-Atlantic region.
Truong can pull up patients' health histories, and he can easily transfer them to an urgent care clinic or a specialist within the Kaiser network. “An integrated system is the backbone of what telehealth should be for patients,” he says. “I can hand off their care to the next physician who sees them, whether that’s later today or a year from now. It closes the loop.”
Integration might be the gold standard, but not everyone in the telehealth industry is keeping up as well as Kaiser and the VA. In 2016 Teladoc recorded 952,081 virtual visits, up from 600,000 in 2015, and 300,000 the year before that. By 2020, the telehealth industry is estimated to be worth $34 billion. It could make a big dent in America’s overextended health care system, if providers and patients use it responsibly.
Truong, who trained in the emergency rooms of Detroit, spent his early days as a doctor treating people who treated the ER as their first and last stop for health care. Their records were incomplete, fractured. It made it hard to care for them. “We couldn’t get down to the meat and bones,” he says. “That’s how I feel about a lot of these companies. There’s no closing the loop.”
To do that, policy and technology can do a lot of the heavy lifting by providing coverage and incentives in the right places. But for telehealth to fully deliver on its promise, people have to start treating their health care less like an
Uber you summon in a thunderstorm, and more like a car that has to carry you the next 500,000 miles.
