A Blog by Jonathan Low

 

Jul 13, 2016

Virtual Health Care Is A Great Idea - But Can It Work For More Than A Few?

Like many potential solutions to knotty problems, telemedicine works best by skimming off the easy, less challenging problems. The tradeoff is that some attention to health, made easier by technology, may be better than none.

The two questions is whether it will ever be able to address more substantive issues - and whether it will cause people to ignore them, believing, perhaps erroneously, that their phone-based analyses are sufficient. JL

Katherine Foley reports in Quartz:

Telemedicine could slip health into our daily routines. 30 states and the District of Columbia have mandated that insurance companies cover virtual healthcare the same way they cover in-person visits. If used properly and diligently, it leaves more time for work, hobbies, and loved ones—and probably with a slightly fuller wallet, too. Yet by being as easy as email, it may be just as easy to neglect.
I think of myself as a healthy person. Most days, I feel okay: No aches and pains, and I’m pretty happy. I exercise and eat a lot of veggies. I’m young. I’m fine.
It’s relatively easy for me to ignore my health. But, it had been years since my last checkup, so I decided to make a few doctor’s appointments. I quickly became annoyed at the idea of going into the doctor’s office: It’s time out of my day, it’s costly even with insurance, and I felt visits were shrouded with this cloud of dread that my doctor would find something worth worrying about. Experiencing these these hurdles firsthand, it’s apparent why so many people end up ignoring their health until it becomes an emergency.
There must be a better way.
 Americans need healthcare that meets them where they are, which is increasingly online or on-the-go. Last year in in the US, about 15 million patients sought some kind of telemedicine—services like Talkspace, Teledoc, and American Well that promise digital mental or physical healthcare—up 50% from 2013. This number is projected to rise by 30% this year, according to the Wall Street Journal. Telemedicine isn’t intended to replace traditional medicine; rather, it’s access to care for those who don’t have it otherwise, due to price or time constraints. Americans need healthcare that meets them where they are, which is increasingly online or on-the-go. But telemedicine is a double-edged sword: although it provides more accessible treatment for some ailments, it can also make it easier to ignore your problems.
For health issues that aren’t an emergency, like coping with a breakup or a bout of poison ivy, telemedicine provides patients with advice or care without the hassle of scheduling and travel. A 2014 survey found that across major cities in America, patients waited an average of five days to two months for visits to the doctors’ offices for minor problems like headaches or sinus infections.
Alan Dappen, a family doctor based in Vienna, Virginia, thinks most visits to the doctors office are unnecessary. “History trumps physical exams a certain percentage of the time,” he said.
In his estimation about 55% of the time he could treat a patient just based on what she told him was wrong. (Other figures put unnecessary visits at about 20% (paywall) and 50% (pdf) from a study in London.) For example, frequent, burning urination points to a urinary tract infection, which can be treated easily with antibiotics. A urine culture could verify the diagnosis in a day or so, but waiting for the results test would take time away from her getting better.
 When patients know that they can get help quickly, they’re more likely to call. Dappen runs a practice called DocTalker, which combines elements of telemedicine into a traditional practice. After patients make an initial visit to his Virginia office (which he promises will be just about 30 minutes), his services are available to them 24 hours a day, seven days a week. One of four healthcare providers (two doctors, a nurse practitioner, and a physician’s assistant) are always on-call, though Dappen said he often gives patients his personal cell phone number so they can call him instead. He can call-in prescriptions for patients anywhere in the US, as long as they’ve seen him within the year for an in-person checkup.
When patients know that they can get personal help quickly, they’re more likely to call (or text or email—he doesn’t care how you get in touch) rather than book an appointment in three weeks time for an issue that may resolve on its own.
Dappen charges $33 per five minutes with a patient—whether it’s in-person or over the phone. He came up with this number by calculating his hourly rates, not unlike freelance workers. And although he’s available for patients whenever they need him, “you don’t owe anything unless you need service,” he said. Usually, he spends about five to 10 minutes interacting with patients virtually, which could amount to $66.
Not all telehealth services take insurance, Medicare, or Medicaid. According to the American Telemedicine Association, only 30 states and the District of Columbia have mandated that insurance companies cover virtual healthcare the same way they cover in-person visits. With state and federally sponsored health insurance programs, the lines are even murkier (pdf) depending on where patients live. But, depending on how you use it, it may save you money.In 2014, a report by the US Department of Health and Human Services found that most insured Americans have an average co-pay of $24 (pdf) per regular office visit, which they will probably seek about three times per year, which would amount to $72 per year. And, if you have a high deductible, $66 for a quick consult may still be less expensive out of pocket.
Geography also becomes less of an issue with telemedicine. Ask the Doctor provides medical advice from general physicians and specialists to patients within 24 hours. These doctors can’t yet provide treatment to patients, but they can tell patients if they should seek follow up care. “[Our service] allows them to move on with their life without having to worry that something is wrong,” Michael Warner, a physician at the Toronto East General Hospital and chief medical officer for Ask the Doctor, said.
Right now, Ask the Doctor is only provided in English, but Warner says the service fields questions from all over the world, particularly related to pregnancy and HIV. Patients ask doctors to look at their lab work for further interpretation or pictures of a rash they’re not sure what to make of. Since the site was created in 2010, it’s answered over 5 million questions. “To us, that means there’s some kind of unmet medical need that exists in every country,” Warner said.
 “You can always reread and rethink conversations with therapists.” Talkspace, a teletherapy platform, also allows patients to begin treatment instantaneously. Upon sign up, you can start the matching process with a therapist, which is also conducted by a professional—no more hunting online or through friends or family. You’re paired with a therapist in 24 hours, and you can begin corresponding as much as you’d like after that. The therapist checks in once or twice a day with responses and additional questions.
“Your messages are always there,” Oren Frank, one of the co-founders of Talkspace, said. “You can always reread and rethink conversations with therapists.” This allows you to better process what they’ve said, or thoughtfully answer when you have time, rather than trying to fire back immediately.
Talkspace also charges for a period of time rather than per session like in traditional therapy. Each week of unlimited message therapy costs $32, amounting to $128 per month. Many in-person therapists don’t actually take insurance, though, and charge hourly rates that can be so the cost of a typical visit can be anywhere from $75 to $200. “Good luck trying to get that kind of service at any other price.” 
“In our observation, you probably need an hour of care or less [per year]” Dappen said. “For that hour, you’d pay me $400 a year. You had me available 24/7, and got what you needed most of the time. Good luck trying to get that kind of service at any other price.”
Studies (paywall) on internet therapy show (paywall) that it can be just as effective as in-person therapy. It does not intend to replace traditional therapy, and teletherapists can’t provide medication for patients who may need medication to treat a mental health condition (only psychiatrists can do that). “[Talkspace] is a different product that opens [therapy] to the 99% that has no access to traditional therapy,” Frank said.
Similarly, Talkspace screens each of its patients to make sure that they’re good candidates for outpatient therapy, which can typically handle issues like grief, eating disorders, and even marriage counseling.
Recently, I decided to try Talkspace. I’d had great success with therapy in the past, and though I didn’t feel my anxiety and self-esteem were in a bad place, I decided to talk through some concerns I had about a relationship. Quickly, my therapist pointed out that the tensions I felt likely existed because some aspects of my mental health probably needed attention. I read the text in the app over a few times with narrowed eyes. I knew she was right but was surprised by the degree she could discern a real, underlying problem from a general scenario, I shut my computer without responding. She was pointing out something I didn’t want to hear, and could easily ignore.
 Telemedicine could be another outlet for the same denial that bars most people from visiting the doctor in the first place. When I finally did get around to going to a primary care physician, he pointed out that I had been ignoring aspects of my health I didn’t think needed attention. And why would I, or anyone, voluntarily submit ourselves for routine health checks, like blood work, when we feel fine? In reality, though, there are a lot of conditions that only become problematic after they’ve been ignored for a long time, like slow weight gain, rising blood pressure or sugar, or moles that have grown unchecked. Part of healthcare, is being face-to-face with a providers so they can remind you of the all the care your body needs—not just for the ailments that are bothering you at present. It may not be what we want to hear, but it’s necessary.
Telemedicine could slip health into our daily routines. If used properly and diligently, it leaves more time for work, hobbies, and loved ones—and probably with a slightly fuller wallet, too. Yet by being as easy as email, it may be just as easy to neglect. And even if patients do seek treatment, virtual providers are getting only the snapshots of patients’ lives they choose to share. Telemedicine could be another outlet for the same denial which prevents bars most people from visiting the doctor in the first place, except maybe worse because it can give users the impression that they are taking care of their health.
At its core, telemedicine is about providing some care for those who may not seek it otherwise—a nobel pursuit to be sure. But we can’t kid ourselves that some attention to our bodies is all we need—it just may be the best that we can do for the time being. Telemedicine absolutely has a place in modern healthcare, but it must be alongside regular visits with providers to keep us honest—if not with our doctors, than with ourselves.

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