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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.

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I’m often asked to do book reviews on my blog, and I rarely agree to them. This is because it takes me a long time to read a book – and then if I don’t enjoy it, I figure the author would rather me remain silent than publish my true thoughts. Most of the reviews that I end up writing are unsolicited, but today is an unusual exception. A colleague asked me to read her book, “How To Be A Rock Star Doctor.” I got half way through when she checked in to see how things were going. I had to tell her that I didn’t agree with some of her advice to young doctors, and I worried that she would be discouraged by my honesty.

I was very pleasantly surprised to find that she welcomed the criticism and actually asked me to write my review – favorable or unfavorable as I saw fit. She is the very first author to take that position (others have thanked me for not writing a review) and I am proud of her for it.

In essence, How To Be A Rock Star Doctor, is an easy-to-read primer for young primary care physicians looking to setup their first outpatient practice. The troubling part of the book (for me) was Dr. Bernard’s approach to the empathy fatigue that can set in for overworked physicians. In her view, we must “fake it” if we’ve lost it or don’t have it.

The book contains specific advice for how to appear empathic. Smiling broadly (no matter how one is feeling internally), dressing in a white coat, and exuding confidence, are recommended because we should see our patient interactions as an acting role – we are on stage, and they are depending on us to look/act the part.

Although Dr. Bernard rightly points out that there is research to support smiling as a means to achieving a happier mood, I was left with a certain uneasiness about the idea of putting on an act for patients. Something about the potential for dishonesty didn’t feel right to me. But then again, maybe the alternative – just being oneself – can create a poor therapeutic relationship if we’re in a bad mood for some reason.

I have heard many times that doctors can be uncaring to patients. Heck, I’ve even blogged about terrible interactions that I’ve had with my peers when I was in the patient role. But what is the solution? Should doctors learn how to imitate the qualities of a compassionate physician to achieve career success, or should we go a little deeper and actually try to be caring and let the behavior flow from a place of sincerity?

On the one hand, any tips to make the doctor-patient relationship go more smoothly should be welcomed… but on the other, if patient care is just an act, then what kind of meaning do our relationships have? If we act empathic do we eventually become empathic? Maybe yes, maybe no.

One thing I’m sure of, Dr. Bernard has opened an interesting discussion about how to handle stress, burnout, and create an excellent therapeutic experience in the midst of a broken healthcare system. She is willing to take criticism, and has endeared herself to me through our email exchanges. While I may not agree with all of her strategies to optimize patient satisfaction, one thing seems clear: she is as advertised — a rock star doctor.

Check out her book and find your own path forward. 🙂

Nurses And Physician Assistants Are Increasing Their Market Share Of Outpatient Medicine

The percentage of hospital outpatient department visits seen only by a physician assistant or advanced practice nurse rose from 10% to 15%, while the percentage of joint physician/nonphysician clinician visits remained at about 3%, health researchers found.

Among other findings in the Centers for Disease Control and Prevention report:
–About three-fourths of the more than 103 million hospital outpatient department visits in 2008-2009 were seen by a physician and 18% were seen by a physician assistant or advanced practice nurse;
–Among visits to a non-physician, 65% were seen by an advanced practice nurse and 35% were seen by a physician assistant;
–The percentage of outpatient department visits attended only by physicians declined from 77% in 2000-2001 to 72% in 2008-2009; and
–The percentage of visits not seen by a physician, physician assistant, or advanced practice nurse remained the same (10%).

Following previous trends, physician assistants or advanced practice nurses are the only provider for visits more often in rural areas, and with younger patients. Read more »

*This blog post was originally published at ACP Hospitalist*

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