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Telehealth: Cost Saver or Cost Driver?

Over 1 million virtual doctor visits were reported in 2015. Telehealth companies have long asserted that increased access to physicians via video or phone conferencing saves money by reducing office visits and Emergency Department care. But a new study calls this cost savings into question. Increased convenience can increase utilization, which may improve access, but not reduce costs.

The study has some obvious limitations. First of all, it followed patients who used one particular telehealth service for one specific cluster of disease (“respiratory illness”) and narrowed the cost measure to spending on that condition only. Strep throat, coughs, and sinusitis are not drivers of potentially expensive care to begin with, so major cost savings (by avoiding the ER or hospitalization) would not be expected with the use of telehealth services for most of these concerns.

Secondly, the patients whose data were scrutinized had commercial insurance (i.e. a generally healthier and younger population than Medicare beneficiaries, for example), and it is possible that the use of telehealth would differ among people with government insurance, high-deductible plans or no insurance at all.

Thirdly, the study did not look at different ways that virtual doctor visits are currently being incorporated into healthcare delivery systems. For example, I was part of a direct primary care practice in Virginia (DocTalker Family Medicine) that offered virtual visits for those patients who had previously been examined in-person by their physician. The familiarity significantly reduced liability concerns and the tendency for over-testing. Since the doctor on the other side of the phone or video knew the patient, the differential diagnosis shrank dramatically, allowing for personalized real-time treatment options.

I’ve also been answering questions for eDocAmerica for over 10 years. This service offers employers a very low cost “per member per month” rate to provide access to board-certified physicians who answer patient questions 24/7 via email. eDocs do not treat patients (no ordering of tests or writing prescriptions), but can provide sound suggestions for next steps, second opinions, clarifying guidance on test results, and identify “red flag” symptoms that likely require urgent attention.

For telehealth applications outside the direct influence of health insurance (such as DocTalker and eDocAmerica), cost savings are being reaped directly by patients and employers. The average DocTalker patient saves thousands a year on health insurance premiums (purchasing high deductible, catastrophic plans) and using health savings account (HSA) funds for their primary care needs. They might spend $300/year on office or virtual visits and low-cost lab and radiology testing (pre-negotiated by DocTalker with local vendors). As for eDocAmerica, employers pay less than a dollar per month for their employees to have unlimited access to physician-driven information.

The universe of telehealth applications is larger than we think (including mobile health, remote patient monitoring, and asynchronous data sharing), and already extends outside of the traditional commercial health insurance model. Technology and market demand are fueling a revolution in how we access outpatient healthcare (which represents ~40% of total healthcare costs), making it more convenient and affordable. As these solutions become more commonplace, I have hope that we can indeed dramatically reduce costs and improve access to basic care.

Keeping people well and out of the hospital should be healthcare’s prime directive. When those efforts fail, safety net strategies are necessary to protect patients from devastating costs. How best to provide that medical safety net is one of the greatest dilemmas of our time. For now, we may have to settle for solving the “lower hanging fruit” of outpatient medicine, beginning with expanding innovative uses of telehealth services.

Cancer Patients May Not Get The Rehab They Need: A Missed Opportunity To Consider

This blog post first appeared at: Curious Dr. George 

Rehabilitation medicine is one of the best-kept secrets in healthcare. Although the specialty is as old as America’s Civil War, few people are familiar with its history and purpose. Born out of compassion for wounded soldiers in desperate need of societal re-entry and meaningful employment, “physical reconstruction” programs were developed to provide everything from adaptive equipment to family training, labor alternatives and psychological support for veterans.

Physical medicine and rehabilitation (PM&R) then expanded to meet the needs of those injured in World Wars I & II, followed closely by children disabled by the polio epidemic. In time, people recognized that a broad swath of diseases and traumatic injuries required focused medical and physical therapy to achieve optimal long term function. Today, cancer patients frequently benefit from comprehensive rehabilitation as they recover from the effects of chemo (neuropathy, weakness, and cognitive impairments), radiation (scarring and range of motion limitations), surgery (flaps, plastics procedures, tumor resection, amputations), and brain injuries (edema, debulking, gamma knife and neurosurgery).

Rehabilitation is a phase of recovery occurring after any major life-changing medical or surgical event. Our bodies are designed to regenerate and repair, though optimizing this process takes skilled guidance. PM&R physicians (also known as physiatrists) are trained to use physical modalities (stretching, strengthening, heat, cold, etc.) to mechanically enhance healing. They prescribe medications to manage pain, spasticity, nerve injury, and cognitive impairments, while also leveraging the power of physical therapy to increase cardiopulmonary fitness, muscle strength and flexibility. PM&R physicians are also experts in neurologic injury, and can adapt exercises to coax spinal cord, brain and peripheral nerve injuries to construct new pathways for movement and repair.

Inpatient rehab’s prime directive is to get patients back home. To succeed at home, patients need to be able to function as independently as possible, using trained assistants for managing the activities that cannot be performed without help. Admission to a rehab hospital or unit offers the patient home practice opportunities – with simulated challenges that can include everything from terrain parks, test kitchens, medication management trials, driving simulators, balance tests, electric wheelchairs and even exoskeletons that allow paralyzed patients to walk again. It is like a robotic Disney World, with endless aquatic and equipment possibilities for restoring movement and independence.

When I discuss admission to inpatient rehab with my cancer patients, I ask them about their goals, motivation, and energy levels. Timing of rehab is important, because it must dovetail with treatment, so that the physical exertion strengthens, not saps, the patient. Often times when a person is newly diagnosed with cancer, they want “everything done” – intensive chemo/radiation/surgery as well as rehab/exercise. But staggering these interventions can be more effective.

In other cases when care is palliative, learning new skills and being fitted with battery or electric-powered equipment can mean the difference between living at home or in an assisted environment. Some successful cancer patients come to inpatient rehab to practice managing their activities of daily living with varied amounts of assistance, preparing for increased needs as time goes on so they can enjoy being at home for as long as possible.

For the physiatrist, cancer is a cause of impairments that can be overcome with creativity and practice, no matter the long-term prognosis. Adaptive equipment, physical exercise, and cognitive retraining may be applied intensively (3 hours a day in the inpatient setting), or at a slower outpatient pace, depending on individual need. Rehab physicians desire to support and sustain patient function at the highest level, and “add life to years.” As such, rehabilitation should be considered an integral part of successful cancer care and management.

Ageism In Healthcare And The Danger Of Senior Profiling

We’ve all heard the saying, “age is just a number.” Nowhere is that more important than in the hospital setting. Over the years I’ve become more and more aware of ageism in healthcare – a bias against full treatment options for older patients. Assumptions about lower capabilities, cognitive status and sedentary lifestyle are all too common. There is a kind of “senior profiling” that occurs among hospital staff, and this regularly leads to inappropriate medical care.

Take for example, the elderly woman who was leading an active life in retirement. She was the chairman of the board at a prestigious company, was an avid Pilates participant, and the caregiver for her disabled son. A new physician at her practice recommended a higher dose of diuretic (which she dutifully accepted), and several days later she became delirious from dehydration. She was admitted to the local hospital where it was presumed, due to her age, that she had advanced dementia. Hospice care was recommended at discharge. All she needed was IV fluids.

I recently cared for an attorney in her 70’s who had a slow growing brain tumor that was causing speech difficulties. She too, was written off as having dementia until an MRI was performed to explore the reason for new left-eye blindness. The tumor was successfully removed, but she was denied brain rehabilitation services because of her “history of dementia.”

Of course, I recently wrote about my 80-year-old patient, Jack, who was presumed to be an alcoholic when he showed up to his local hospital with a stroke.

Hospitalized patients are often very different than their usual selves. As we age, we become more vulnerable to medication side-effects, infections, and delirium. And so, the chance of an elderly hospitalized patient being acutely impaired is much higher than the general population. Unfortunately, many hospital-based physicians and surgeons — and certainly nurses and therapists — have little or no prior knowledge of the patient in their care. The patient’s “normal baseline” must often be reconstructed with the help of family members and friends. This takes precious time, and often goes undone.

Years ago, a patient’s family doctor would admit them to the hospital and care for them there. Now that the breadth and depth of our treatments have given birth to an army of sub-specialists, we have increased access to life-saving interventions at the expense of knowing those who need them. This presents a peculiar problem – one in which we spend enormous amounts of resources on diagnostic rabbit holes, because we aren’t certain if our patients’ symptoms are new or old. Was Mrs. Smith born with a lazy eye, or is she having a brain bleed? We could ask a family member, but we usually order an MRI.

My plea is for healthcare staff to be very mindful of the tendency to profile seniors. Just because Mr. Johnson has behavioral disturbances in his hospital room doesn’t mean that he is like that at home. Be especially suspicious of reversible causes of mental status changes in the elderly, and presume that patients are normally functional and bright until proven otherwise.

Last month I hit a new age record at my rehab hospital – I admitted a charming, active, 103-year-old woman after a small stroke caused her some new weakness. She was highly motivated in therapy, improved markedly and was discharged to an independent living center. I bet she will live many more years. When I joked that she didn’t look a day over 80, she winked and told me she had stopped counting birthdays years ago. She said, “It doesn’t matter how old you are, it matters what you can do. And I can do a lot.”

When It’s More Important To Save A Lifestyle Than A Life – Jack’s Story

Even though I don’t have an outpatient practice, I like to keep in touch with some of my patients after they’ve discharged from the rehab hospital. Jack is one of my very favorite success stories.

I met Jack in a small regional hospital in rural western America. He had been admitted with sudden onset weakness, and during the intake process, accurately described his daily evening cocktail habit. Unfortunately, this led the clinicians down the wrong diagnostic pathway, presuming that alcohol withdrawal seizures were the cause of his weakness (due to a presumed “post-ictal” state).

A brain MRI was unremarkable, and so a fairly high loading dose of anti-seizure medications were started. Poor Jack happened to be very sensitive to meds, and reacted with frank psychosis. Days later he was still not in his right mind, and so a rehab consult was requested for “encephalopathy due to alcohol withdrawal.”

When I met Jack, it was clear on first glance that… [click here to read the rest of the story] or go to this link:

http://cliniciantoday.com/when-its-more-important-to-save-a-lifestyle-than-a-life/

The Amazing Coincidence That Brought A Physician And Patient Together Across The Country

As the new medical director of admissions for St. Luke’s Rehabilitation Institute in Spokane, Washington, it is my job to review all patient referrals to our hospital. Imagine my astonishment when, while traveling to New Orleans, I received an email about a patient at Tulane Medical Center who was requesting admission to St. Luke’s. This dear lady was from Spokane, but had fallen ill while visiting her family on the other side of the country, in Louisiana.

I quickly discovered via Google Maps that she was in a hospital bed only three blocks from my hotel room. I called the case manager and nurse at Tulane and asked if it was OK for me to stop by the patient’s room for an interview. They were surprised to hear that a consult physician from Washington was going to meet their patient in person, but thought it would be fine.

When I arrived, the patient’s son greeted me. He was pacing the halls, worrying about how he was going to get his mom home. There was only one direct flight per week, and it was scheduled for the next day. He had booked the ticket on Southwest Airlines on a lark.

I explained that I was from St. Luke’s, the facility that he hoped would admit his mom for further care.

He was dumbfounded. “What are you doing in New Orleans?” he asked.

“I’m here on a business trip,” I said, “and I heard your mom needed rehab. I wanted to look in on her and make sure she’s ready to transfer home. I reviewed her chart and she seems to be a perfect candidate.”

He smiled and sputtered that he thought the case managers had just sent out the referral request a few hours prior. “How on earth did you get here so quickly?” he marveled.

I explained that email and digital chart access make a big difference these days and reassured him that his mom would likely be able to catch her flight the next morning.

As I entered the patient’s room, I introduced myself as a doctor from St. Luke’s in Spokane, who had come to see if she was ready for admission. She looked at me with bright, quizzical eyes.

“I thought this was going to take weeks,” she said. “I was in such a state. I prayed that God would find a way to get me home just a few hours ago, and now you’re here. This must be divine intervention.”

I smiled and briefly examined her, noting a PICC line and Foley catheter. She wrote me a list of “must eats” in New Orleans and explained where I could find the best fried oysters and po’boy sandwiches. Her attending physician then came in, accompanied by a medical resident. The resident explained that I was here from the accepting facility in Washington state.

“This never happens,” the attending stated, matter-of-factly.

“It’s a crazy coincidence. I am the admissions director, and I happened to be three blocks from here when I received an email about this patient,” I said. “I reviewed a copy of your medical records and believe she is an excellent rehab candidate. Because I was right around the corner, I figured I’d facilitate her transfer in person. It’d be great if we could leave her lines and tubes in for the trip. … I’d like to give you my card, in case you have other patients who need rehab in Spokane.”

The attending chuckled as she looked at my business card. “I’m not sure how many others we’ll be sending your way.”

“You never know.”

Dr. Val Jones and patient Patricia Crocker-Fox in Spokane, WA.

The patient transferred to St. Luke’s the very next morning, arriving before I did. She made an excellent recovery, and after three weeks of hard work, she was able to stand and walk again.

She gave me permission to write about this amazing journey, and I had a hospital friend take a photo of us together on her final day at St. Luke’s, next to a full-scale replica of the same Southwest Airlines airplane in which she traveled to us from New Orleans. We use it in our gym to help patients with injuries and disabilities practice getting in and out of airplanes. Southwest Airlines donated it to us some time ago — yet another coincidence!

Stories like these make me glad to be a physician. I love knowing that I may be called upon at any time — wherever I am — to help people in extraordinary ways.

And yes, I did gain about five pounds on my trip. What can I say? I simply had to take my patient’s advice on Cajun delicacies before I flew home!

**This post was originally published on the Barton Associates Blog.**

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