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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.

Why In-Person Visits Will Always Be The Foundation Of Quality Healthcare

In a recent Forbes editorial, conservative commentator John Goodman argues that the Texas Medical Board is sending the state back to “the middle ages” because they are trying to limit the practice of medicine in the absence of a face-to-face, doctor-patient relationship. He believes that telemedicine should have an unfettered role in healthcare – diagnosis and treatment should be available to anyone who wishes to share their medical record with a physician via phone. This improves access, saves money, and is the way of the future, he argues.

He is right that it costs less to call a stranger and receive a prescription via phone than it does to be examined by a physician in an office setting. But he is wrong that this represents quality healthcare. As I wrote in my last blog post, much is learned during the physical exam that you simply cannot ascertain without an in-person encounter. Moreover, if you’ve never met the patient before, it is even more likely that you do not understand the full context of a patient’s complaint. Access to their medical records can be helpful, but only so much as the records are thorough and easy to navigate. As the saying goes: garbage in, garbage out. And with EMRs these days, auto-populated data and carry-forward errors may form the bulk of the “narrative.”

Telemedicine works beautifully as an extension of a previously established relationship. Expanding a physician’s ability to connect with his/her patients remotely, saves money and improves access. But bypassing the personal knowledge piece assures lower quality care.

I currently see patients in the hospital setting. I run a busy consult service in several hospital systems, and I have access to a large number of medical records, test results, and expert analyses for each patient I meet. Out of curiosity, I’ve been tracking how my treatment plans change before and after I meet the patient. I read as much as possible in the medical record prior to my encounter, and ask myself what I expect to find and what I plan to do. When medical students are with me, we discuss this together – so that our time with the patient is focused on filling in our knowledge gaps.

After years of pre and post meeting analysis, I would say that 25% of my encounters result in a major treatment plan change, and 33% result in small but significant changes. Nearly 100% result in record clarifications or tweaks to my orders. That means that in roughly 1 in 4 cases, the patient’s chief complaint or diagnosis wasn’t what I expected, based on the medical record and consult request that I received from my peers.

If my educated presumptions (in an ideal setting for minimizing error) are wrong 25% of the time, what does this mean for telemedicine? The patient may believe that they need a simple renewal of their dizziness medicine, for example, but in reality they may be having heart problems, internal bleeding, or a dangerous infection. Let’s say for the sake of argument that the patient is correct about their needs up to 75% of the time. Are we comfortable with a >25% error rate in healthcare practiced between strangers?

Goodman’s cynical view of the Texas Medical Board’s blocking of telemedicine businesses for the sake of preserving member income does not tell the whole story. I myself have no dog in this fight, but would side with Texas on this one – because patients’ lives matter. We must find ways to expand physician reach without eroding the personal relationship that makes diagnosis and treatment more customized and accurate. Texas is not returning healthcare “to the middle ages” but bringing it forward to the modern age of personalized medicine. Telemedicine is the right platform for connecting known parties, but if the two are strangers – it’s like using Facebook without access to friends and family. An unsatisfying, and occasionally dangerous, proposition.

Combining Telehealth And Mobile Technology To Improve The Quality Of Health Care

Bill Crounse, MD, Senior Director, Worldwide Health, Worldwide Public Sector Microsoft Corporation shares his insights and describes four leading trends and technologies that will transform health and health care in 2012 and beyond.

These leading technologies include:  cloud computing, health gaming, telehealth services and remote monitoring/mobile health.

Telehealth, Remote Monitoring, Mobile Health

I’d like to focus on telehealth and remote monitoring/mobile health since I feel telehealth is the nucleus of patient care, and telehealth can help reduce health care costs, and improve quality health care for patients. Telehealth technology combined mobile technology such as smartphones will make monitoring patients conditions easier and more efficient, and “cheaper and more scalable.

Patient Quality Health Care

Through the Accountable Care Organizational Model (ACO), the core concept is to Read more »

*This blog post was originally published at Health in 30*

The Power Of Social Media Networking In Health Care

In a recent Harvard Business Review Blog, David Armano writes about the six pillars of influence that lead to measurably favorable outcomes.

To achieve measurably better health, the pillars Armano explains can certainly be adopted.

He notes how the “social web can amplify signals, influence behavior and lead to action.”

Social networking has changed the landscape in health care.  Technology has paved the way for instant communication and feedback.

While some companies continue to question the value of social media networking, debating whether or not they should be on Twitter or Facebook, others have superseded the hesitation, and are presently into the next phase of social networking. Read more »

*This blog post was originally published at Health in 30*

UnitedHealth Group Releases A Somewhat Inadequate Report On Modernizing Rural Health Care

The UnitedHealth Center for Health Reform and Modernization released a white paper today on Modernizing Rural Health Care.  To quote from the UHG presser,

  • [The paper] projects an increase of around 5 million newly insured rural residents by 2019 – even as the number of physicians in rural America lags
  • Quality of care is rated lower in rural areas in 7 out of every 10 health care markets; both physicians and consumers in rural areas more likely to rate quality of care lower than those in urban and suburban markets
  • Innovations in care delivery – particularly telemedicine and telehealth – can absorb future strain on rural health care systems

The paper inventories the current state of health care for the 50 million Americans living in a rural setting — and it’s not pretty.  The question, of course, is why does rural health compare unfavorably to urban health metrics, and what can be done to improve matters? Read more »

*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*

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