What excites me about telehealth (Part 1 of 2)
Originally published on my personal blog on August 2, 2020
My first encounter with health care dates back to high school when I volunteered in the Pediatric Urgent Care unit of Trillium Health Centre. While I was very impressed by the standard of care at Trillium, there were a few problems that bewildered me. Working parents rushed home to bring their sick kids to the general hospital, because there was limited urgent care available outside 9 to 5. Patients of varying ages, infants to teenagers, with coughs, a suspected ear infection or fever sat in the waiting area for 2 to 3 hours to see a doctor.
Over the years, I continued to have more meaningful interactions with health care. I attempted my own telemental health start-up, worked at a medical device start-up at the Perelman School of Medicine, and currently study health care as a venture capital investor. I have met many people working on noble aspirations and innovating health care. Especially, I am excited that many problems in health care are being solved by telehealth, and my team at LG Technology Ventures participated in Amwell’s recent $194MM funding round (press release).
Here, I would like to share what excites me about telehealth.
Why does telehealth make sense?
"Telehealth is the use of digital information and communication technologies, such as computers and mobile devices, to access health care services remotely and manage your health care. These may be technologies you use from home or that your doctor uses to improve or support health care services" – Mayo Clinic
Telehealth helps address accessibility issues. On the recent Freakonomics Radio episode on telehealth (link), Dr. Ellimoottil at Michigan Medicine explains:
“We’re seeing patients from all over the state who sometimes travel four hours just to have a 15-minute consultation about their kidney stone. And to be honest, I probably knew the answer about how I was going to manage that patient when I looked at their C.T. scan”.
Telehealth enables rural patients to interact with their care providers without spending hours traveling to and from the doctor's physical location. This is important for patients in a variety of circumstances: low-income patients who might be sacrificing a day’s worth of wages to travel for a doctor’s visit, elderly patients who might depend on others for transportation, or patients who have to put themselves at great danger traveling during challenging weather conditions (perhaps I feel compelled to add this due to my experience living through blizzards in Canada).
Convenience and accessibility are also highly valued by urban patients. Many of my friends, otherwise healthy in their 30s and 40s, postpone trips to the doctor because of the inconvenience of traveling or taking time off work. These conditions, which might have been mild at the start, often worsen over time in the absence of timely medical attention.
Exhibit A: Patient attitude towards telehealth by age group
(Source: Amwell, Barclays)
2) Reducing Disease Spread
Telehealth can help keep immunocompromised patients out of hospitals or clinics where they might contract other illnesses or diseases. Conversely, patients with infectious diseases can be kept out of hospitals or clinics to control cross infection while still being cared for. In U.S. hospitals, cross infection affects approximately 5% to 10% of patients, costing over $4.5 billion.
3) More Efficient Delivery of Care
Health care is the ultimate operations problem, and telehealth is the perfect opportunity for pooling. How do you staff enough physicians in every population center, big and small, around the country and ensure a certain service level at all times? If there are fewer sick patients in San Francisco and more in San Diego in a given day, some San Francisco physicians can see San Diego patients via telehealth. Using pooling and the flexibility afforded by telehealth, you can ensure a higher service level (e.g. shorter patient wait times) with the same or fewer resources in the overall system.
Exhibit B: Much like the manufacturing example below, flexibility afforded by telehealth can enable optimization of physician resources (or "utilization") and more patients served (or "sales")
(Source: Professor Hummy Song, Wharton School)
Risks and Challenges
Since the interaction is virtual, there is a limit on the types of care that can be provided through telehealth. The doctor cannot listen to your lungs or perform an ultrasound virtually (yet). Nonetheless, telehealth is still valuable as a triage process to determine which patients need to be seen in-person. Consults and routine follow-ups that happen to be almost entirely verbal in nature are most conducive to being converted to telehealth.
2) Physician Reimbursement
Dr. Daniel Horn, a primary care physician at Massachusetts General Hospital explains the importance of telehealth interactions with patients:
"I made 30 such calls last week to people living alone, struggling with food insecurity or grappling with mental health issues. These were some of the most meaningful conversations of my career. Our primary-care teams have undoubtedly saved many lives with the telephone surveillance, which takes about 30 percent of our doctors’ time and nearly all of our nurses’ time" (link).
Unfortunately, physicians are not necessarily being reimbursed by payers for this big chunk of time spent on follow-up telehealth calls. Physicians need to earn a living and cover many costs, depending on the structure of their practice, such as wages for nurses and other staff, equipment, and rent. A national survey of over 2,600 primary care physicians conducted in April by the Primary Care Collaborative found that “financial strain on primary care practices is impacting their ability to keep staff employed and doors open” (link). We have to find a financial model that works for everyone.
Centers for Medicare & Medicaid Services (CMS), the largest payer for health care in the U.S., has expanded telehealth coverage on a temporary basis, including cutting back on HIPAA enforcement, reimbursing telehealth services at parity with in-person visits, and letting physicians practice across the country, versus state-by-state. Regulation changes after COVID-19 will affect the shape and form in which telehealth exists going forward.
According to NCBI, the length of an average in-person doctor’s visit was 17.4 minutes. I have encountered telehealth start-ups that claim to take inefficient time out of a physician-patient interaction using technology, resulting in an average visit being only 2 minutes. This is probably not an apples-to-apples comparison. Nonetheless, if the average length of a telehealth visit is indeed shorter and there are fewer “services” performed (e.g. a physician cannot use the otoscope to look inside your ear in a telehealth visit), is there an argument for reducing the reimbursement level for telehealth visits? Alternatively do we need a different reimbursement model altogether in light of the financial strain on primary care practices discussed earlier?
In Part 2, I will share my outlook on the future of telehealth. Please stay tuned.
Views expressed in this post are of my own. These do not represent views of any organization or employer I am currently or was previously associated with.