Telehealth: The 21st Century House Call

Jacqueline Risley
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Contributing Author
Wednesday, September 28, 2011

Renowned New York Times columnist Paul Krugman recently contended that "Patients are not Consumers." Because the nature of the doctor-patient relationship, he says, we can't treat healthcare like just another business transaction. But the truth is that patients do choose their doctors the same way they choose other services and expect the same levels of responsiveness. Why else would Walmart be in the healthcare business?

Physicians can't build a bond that promotes ideal care if they don't attract and retain patients in the first place. Technology is often blamed for coming between physicians and patients. But telehealth (health services delivered by phone or online) can strengthen the bond with patients, improve outcomes and increase patient and physician satisfaction. It may even attract new patients.

According to a a survey by Intuit Health, "The convenience of anytime, anywhere access is so important that almost half [of the patients surveyed] would consider switching doctors for a practice that offered the ability to communicate and complete important health care tasks online." Even President Obama is onboard with telehealth, mentioning it in his 2011 State of the Union Address.

Physicians and patients are very familiar with using the Internet, email, texting, instant messaging and video conferencing. Teleheath solutions that have been reviewed for HIPAA and meaningful use requirements meet the security and interoperability healthcare providers need, so why aren't more doctors communicating with their patients this way? Unfortunately, many insurance companies don't reimburse physicians unless they physically meet with the patient, and doctors can't afford to provide uncompensated care.

"Doctors have been obligated not to converse with patients," says Nathanial Findlay, CEO of Hello Health, which develops Web-based patient communication, practice management and EHR solutions. "They are paid on volume, not quality, so they have to make a patient come in to read lab results to them. Doctors' costs are increasing and reimbursements aren't. Something has to give. Telehealth provides a mechanism for better communication. It frees the doctor and the patient to have a 21st century relationship."

Patients pay a modest monthly fee to use the Hello Health's online services, which are designed for one- to five-member physician practices. This offsets out-of-pocket expenses for the practice. Findlay says this model is very successful for physicians who operate on a direct-pay basis, particularly in specialties such as internal medicine, primary care, pediatrics and psychiatry.

American Well, which provides an online care suite, is one telehealth service making inroads with insurers. The company has agreements with a number of major carriers to provide telehealth services for which physicians are reimbursed. "Insurance companies are willing to shift care to more appropriate cost centers. ER and doctor's office visits are costly. Rendering services at home saves money," notes Roy Schoenberg, MD, president and CEO of American Well. "It's another tier of care. Obviously, there are times when telehealth is not appropriate, but 50-60% of the time an office visit is spent talking and reviewing records, and telehealth is perfectly appropriate for that."

One prominent national health plan opened it up its American Well services to non-members on a fee-for-service basis. "It gives patients the convenience of getting any physician from your living room at a price point consumers will accept," Schoenberg points out. "A patient will pay $45 out of pocket to get in right now." Historically focused on large carriers and delivery networks, American Well recently announced a version of the platform suitable for smaller physician practices.

Some, like Krugman, might ask if such a model is impersonal and unprofessional. Getting a quick email or text from a doctor is more personal than requiring a formal appointment for the simplest communication. And we are accustomed to paying professionals for their time. A lawyer, for instance, gets paid for every minute s/he spends providing expertise on the phone or via email.

Freedom to Practice the Way Physicians Want

"At the end of the day doctors want to see fewer patients, increase quality for the patients they see and make more money," says Findlay. "This technology will help them do that." Because these services are Web-based, doctors and patients can access them from virtually anywhere, giving physicians the freedom to work when and where they want.

Reduced costs and greater flexibility are especially important for practices transitioning to concierge care or an accountable care organization (ACO). In concierge care, physicians charge a limited number of patients a set fee in addition to insurance coverage in exchange for guaranteed doctor availability. Telehealth can replace some consultative office visits, making it easier for physicians to meet those obligations.

ACOs are compensated based on a combination of improving outcomes without increasing costs. "The recent HHS [Department of Health and Human Services] documentation to certify ACOs repeatedly mentions that part of the parameter is adoption of technology like telehealth," notes Schoenberg.

"An ACO takes on risk for its own patients," he adds. "If you have a 72-year-old diabetic patient who is not balanced, you need to follow up. Maybe even weekly. Patient compliance and expense will both be problems. A doctor or nurse can meet with the patient weekly via video conference. It may be only five minutes, but the relationship with the patient is significantly enhanced."

Making Life Easier for Patients

Patients also appreciate the flexibility telehealth provides. Have you ever tried to get a mildly confused 80+ year old woman with advanced osteoporosis to the doctor in a snowstorm and wait with her in a waiting room? As someone who has, I know patients' families will be happy to facilitate (and pay for) a telehealth visit if it reduces the number of times they need to take half a day off work to do that.

"There are so many end use cases," says Schoenberg. "Patients may have chronic conditions that make coming into the office a barrier. Parents of young kids want to know if they should burn the rest of their night in the ER. Patients with high deductibles need to know if they really need an expensive physician or ER visit."

Telehealth could potentially reduce hospital readmissions. Physicians or hospitals can set up online care clinics that allow them to check in with the patient and reiterate/clarify discharge instructions to prevent complications. "If they show up in ER, it's usually expensive, late from a treatment perspective and listed as a readmission," Schoenberg points out.

What's Next for Telehealth

Findlay and Schoenberg agree that biometric monitoring, such as vital signs and blood glucose, is the next evolution for products like theirs. "We're building hooks right now to support wireless monitoring," reports Findlay. "The doctor will have a dashboard view and see when something is going wrong. This makes telehealth very relevant for improving patient care. Five to ten years out, there will be machine learning capability and auto-decision support."

Findlay and Schoenberg agree that biometric monitoring, such as vital signs and blood glucose, is the next evolution for products like theirs. "We're building hooks right now to support wireless monitoring," reports Findlay. "The doctor will have a dashboard view and see when something is going wrong. This makes telehealth very relevant for improving patient care. Five to ten years out, there will be machine learning capability and auto-decision support."

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