Working from Home
Americans are doing more and more activities from the comfort of their home and its no surprise – the frustration of showing up to a business only to find they are closed or worse short-staffed and instead of dealing with the customer in front of them the staff are on the phone answering queries. Bypass the line and move to the front of a virtual queue from the comfort of your own home is appealing.
Online Queuing Systems
There is even a sophisticated queuing mechanism when there is limited availability for a resource as I discovered when I tried to score tickets to the Harry Potter show in London
You had to be quick to join this queue virtually
This experience was managed comfortably from my laptop as I sat sipping coffee and checking in occasionally while I continued to work on other things on my laptop. I think it would have been an even bigger disappointment to have spent that time in a line somewhere only to find there were no more tickets left by the time it was my turn.
Compared to my experience getting tickets to the Kusama Infinity Mirrors exhibition at the Hirshhorn Museum which was a physical process I went through recently having failed to score tickets in the online system. This process required early rising, driving into town, expensive parking and then standing in line for 4 hours to get a ticket (it was worth it)
Getting an Appointment
Telehealth has many of the same elements to recommend it. The hassle of making an appointment – which in a recent post online was filled with frustration that started with doctors’ offices, not taking new patients and the ones that did not have available appointments for 6 months! Assuming you can make it past this assault course and get an appointment that is convenient for you the system requires driving to the office, sitting in a waiting room, and being subjected to loud obnoxious daytime television broadcast while you wait for your physician encounter that could last minutes. Some physician exams do involve more serious health issues, but most are routine visits to refill prescriptions and see to minor illnesses and infections, needs that could easily be met with video chat.
Why Has Telehealth Not Taken Off
Discussing this with a colleague recently he highlighted the fact that the leaders of the American Telemedicine Association were famous for saying “This is the year for Telehealth”, every year for the past 20 years
This reminds me of an article I wrote back in 2005, I wrote a piece that continues to show up in my inbox as being used and linked to. It was featured in the Health Management Technology Journal titled “Is Speech Recognition the Holy Grail”. I was frequently quoted and referenced as saying
“Speech Recognition has been 2 years away for the last 10 years and its still 2 years away”
So what happened and why do studies suggest that instead of reducing visits and costs it has the opposite effect? Telehealth drives up healthcare utilization and spending – yes you read that correctly. The report, published Monday in the journal Health Affairs, found that although telehealth appointments are cheaper than in-person and emergency room visits, the online and virtual resources encourage vast new utilization, ultimately driving up healthcare spending
The report, published Monday in the journal Health Affairs, found that although telehealth appointments are cheaper than in-person and emergency room visits, the online and virtual resources encourage vast new utilization, ultimately driving up healthcare spending
In one of those perverse unintended consequences – providing easy(ier) access to healthcare services
The convenience of telemedicine is encouraging people to seek care when they normally wouldn’t, ….You don’t even have to go anywhere … you just have to pick up the phone
Their recommendation – encourage more cost-sharing for consultations to encourage patients to think more critically what they elect to seek medical consultation for. It’s a familiar argument and one that circulated frequently amongst General Practitioners in the United Kingdom’s National Health Service (NHS) who faced a barrage of requests for care at all hours of the day, night, and weekend for conditions that were either trivial or at a minimum non-urgent. But when a service is valued at zero (that’s not to say that it has no value just that the perception is that it has a value or cost of zero) the usual filters fail to be applied.
Healthcare is Different
Normal economic models are hard to apply in healthcare – introducing a co-pay or shared cost model has its own set of unintended consequences. Too high and you discourage legitimate requests for help from patients and this typically affects the vulnerable and poor disproportionately. Too low and it fails to influence the behavior sufficiently to warrant the additional administrative burden and overhead of introducing these mechanisms. But that is true too in other industries – we pay for our own car maintenance and don’t look to the car insurance provider to pay for tire and brake replacement. But when funds are tight people will avoid maintenance and check-ups that ultimately could have saved significant damage and higher costs of repair. But failure in healthcare can be catastrophic and life-ending – a car is just a car.
Ultimately I think it requires a retraining of the individual in better self-care and management and a stronger closer relationship with a trusted healthcare professional who is seen as a partner in the process. I have that with my local garage – I found through a personal recommendation and am a loyal user for years. I have a trusting relationship – unlike some of my experiences with garages that have set up programs that incentivize the employees to sell unnecessary services and repairs this garage does not. The inflection point for me in trust was the time I took one of my cars in to solve an intermittent problem – they had the car for 2 days trying to replicate and diagnose and ultimately were unable to reproduce the problem and could find no underlying problem – the charge for the service – zero. When I asked why I was told they had carried out no maintenance or repairs.
We can achieve the same in healthcare but it requires centering the services around the Primary Care and the Medical Home. I made this point in this piece Give consumers the telehealth option they really want: Virtual visits with their own doctor. Separating out services is like going to the cheap oil change shop like Jiffy Lube. You can get a cheaper oil change and check up but their model is designed to identify problems and sell you on other services. In some cases, I’ve had recommendations for additional services only to be told by my trusted mechanic they are not required.
The Telehealth service providers offer a valuable and important tool – even more so for some rural communities and places that have limited access or low penetration of available clinical professionals – but ultimately if the care is not integrated it will likely have the tendency to increase utilization and has the effect that my colleague described of increasing visits to your healthcare providers.
A telehealth doctor or nurse practitioner can give great episodic care, but those episodes don’t look at the whole patient. Patients also need someone who looks at their risks for chronic disease, such as obesity, type II diabetes and high blood pressure, and guides them toward lifestyle choices that prevent those diseases. And patients also need someone who can connect the dots — a provider who knows and understands their history and can view current symptoms in the context of the patient’s overall health. That’s tough to do if you see a different provider every time, especially if that provider does not have access to your records when he or she writes a prescription or suggests a treatment. It’s why emergency rooms are not a good place to get primary care — not only is it expensive, but the doctors often lack access to critical information.
Integrated Telehealth
To avoid telehealth becoming a cheaper version of emergency room care we must connect telehealth to patient-centered medical homes and offer our clinicians a means to offer this service as part of their total package. We see the early stages of this albeit for an elite few that can afford it with Concierge Practices (The Doctor Is In. Co-Pay? $40,000) that customize care. Reminds me a lot of the service the General Practitioners have offered and still do in England as part of the NHS with home visits included. But enabling this for more people will require some changes to the system especially the reimbursement model that currently incentivizes activity, not wellness or care. Providing technology to offer support and guidance around minor ailments and triage the limited clinical resources directing patients to access them when necessary would help. The Family Practioner with the patient becomes the conductor and manager supporting the delivery of care and drawing on the necessary resources. Their capability is extended through Telehealth allowing them to interact with many more patients remotely and saving unnecessary trips to the office but being rewarded for the care management.
Incremental Improvements in Telehealth
We have been on the cusp of acceptance and widespread roll out for a long time – finding some small step towards that in your practice or as a patient would help move more people to this model and begin showing the value. From the patient consumer perspective being open to the channel and using it where available in lieu of care to understand the experience would help. Think back to when airlines first offered kiosk check-in. Were you one of the many people who said not me ever….. and now it’s your preferred method?
- Accepting the value of remote access and using the existing technology in place can help jump-start the process
- Telehealth can be as simple as a telephone call – for some of the major providers that are a big part of the service they offer
- Adding simple video chat will help expand the channel and allow an exploration of the medium to understand better how it can apply – perhaps starting unofficially with family
- Make Telehealth one of the channels that your Patients can Access you – the reimbursement models may not support this model quite yet but it will undoubtedly induce loyalty and improve the care
Do you have any better suggestions? What small change have you seen that makes a difference in the use of Telehealth services. What one thing could we do that would have a big impact in this area?
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