Brainstorm Health: The Telemedicine Block, Pharma Drug Price Hikes, Mental Health Education

Even if you’ve never seen the reproductions of Rockwell’s celebrated doctor paintings—the gray-haired doc, still donning his green winter scarf, taking the pulse of a porcelain doll; the gray-haired doc eyeing a thermometer at the foot of a young patient’s bed; the gray-haired doc washing his hands as a young patient pulls up his pants—you’ve seen the image in your head.

White smock. Stethoscope. Family doctor with kind eyes and infinite patience.

But on the eve of this July 4th, the holy day when we gather with family and friends to memorialize the American virtues of patriotism, cold beer, and barbecue, I tell you this other bit of cherished Americana is no more. The family doctor has left the building. His white smock is now a rental, leased out in 15.7-minute increments.

The glinting eye and infinite patience has given way to something utterly transactional: a CPT code for Evaluation and Management—otherwise known as the post-millennium “office visit.”

And yet, we ever-nostalgic folk still cling to it.

My question is why? Why do we wait anxiously for appointments to sit anxiously in waiting rooms filled with other anxious souls and torn taupe furniture? Why, in an age of digital everything and virtual manythings, do we still journey to a medical office building for a mere flash of face-time when there is a seemingly good alternative in telemedicine?

The answer, I suspect, is tied to the word “seemingly.” Many of us just don’t believe that the care is as good when it’s delivered remotely.

Indeed, countering that view and establishing that parity in care quality firmly in American minds may well be the key to unlocking the cost savings and convenience that the digital health revolution (seemingly) promises. And here, we seem to be just at the beginning of the effort.

The concept of telemedicine (or telehealth, as it’s sometimes called) has been with us for decades. (Some place its birth back to the introduction of the telephone, but I wouldn’t go that far.) Surprisingly, though, there remains a relative dearth of academic studies comparing outcomes from real and virtual medical visits.

In 2015, Cochrane, an 11,000-member collaborative that evaluates clinical evidence in medical practice, “assessed the effectiveness, acceptability, and costs of interactive telemedicine, delivered in addition to, or as an alternative to, usual care as compared to usual care alone” in 93 randomized controlled trials (a fair sample, but actually a modest number of trials in the realm of the Cochrane meta-analysis). Overall, the use of telemedicine was found to either lead to similar outcomes as face-to-face visits (in managing heart failure, for instance) or to better care (in controlling blood glucose, for example, in people with diabetes).

Remote evaluation by teleconferencing seems to be just as effective as in-office assessment in tasks ranging from diagnosing stroke to treating bulimia, according to that limited literature. And patient satisfaction, on the whole, has been shown to be pretty high.

Some health systems have pushed virtual engagements with their healthcare staff—more than half of Kaiser Permanente’s “visits,” for instance, were done through online or smartphone interactions in 2016. And clearly there’s investor interest in the concept, too. American Well, a telehealth company, has raised more than $300 million in financing as of June 28, according to Chrissy Farr at CNBC. Yet many in the healthcare world have been slow to the migration. That’s in part because of patient resistance, as noted above.

But, interestingly, it’s also because of health insurer reticence, if not resistance. While 35 U.S. states have enacted telemedicine parity laws—which mandate that insurers pay for services rendered by telemedicine that would ordinarily be covered if patients visited the office in person—some insurance providers (and some health experts too) have worried that embracing virtual visits will actually encourage more healthcare consumption, not less. (And by some studies, the prices for remote visits aren’t that much cheaper anyway.)

But that may be changing: Insurance companies may at last be warming to the tele-approach. Witness one as-yet-unpublished study in late June that was presented at the AHIP expo in San Diego. AHIP is the main trade group for America’s health insurance plans—and this particular study was sponsored by Humana and undertaken by Doctor on Demand (yes, a telemedicine company). That said—and with all the expected caveats, eyebrow raising, and Hmm-ing aside—the numbers in the study are notable.

Researchers examined nearly 5,500 medical system encounters between 2016 and 2017, divided evenly between virtual and in-office visits and matched for diagnosis, severity of the cases, household income, region of the country, and other factors. Then they looked to see whether either group had more near-term follow-up visits for the same diagnosis (either to a physician or emergency room), an indicator that might suggest that the initial problem wasn’t properly or fully addressed.

Patients in the telemedicine group had roughly the same number of physician follow-ups (6.6% within 14 days) and subsequent ER visits (1.3%) as those who initially visited the doctor’s office in person (5.1% and 1.1%, respectively). Follow-up visits to urgent care within those first two weeks were a little higher in the former group (0.9% versus 0.1%), but follow-ups overall during the first two months were actually lower in the telemed cohort.

One more takeaway: Doctors who saw patients remotely in this study prescribed fewer antibiotics (36.1% of visits) than those who saw patients in the office (40.1%)—though both cohorts, I’m guessing, prescribed too many.

The biggest difference between the two groups? The covered amount for each type of examination. Telemedicine visits were paid out at an average of $38 versus $114 for face-to-face. That’s the important bottom line, if we’re ever going to get serious about controlling healthcare costs in this country.

So when will the telemedicine migration finally take off? Well, you’d have to ask Norman Rockwell’s doctor that. And he’s in with a patient.

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Enjoy the Fourth! Brainstorm Health is taking a short holiday. We’ll be back to business on Monday, July 9.

DIGITAL HEALTH

Let's talk about Amazon-PillPack. As with so many things Amazon, there's a bit of debate about how revolutionary/not-that-big-a-deal/disruptive/multi-industry-threatening the company's latest project will ultimately be. This time around, it's Amazon's purchase of PillPack, which has inspired a whole new wave of speculation about the firm's health care ambitions following the recent announcement that Atul Gawande will be heading up the still-nebulous Amazon-JPMorgan-Berkshire Hathaway health venture. On the one hand, Amazon customers may be able to take advantage of the PillPack services rapidly after the deal closes; but it's also just an initial foray into a complicated, highly (yet inconsistently) regulated, and generally risk-prone industry. One big question: How will Amazon deal with those little-known but hugely powerful players across the pharmaceutical supply chain, such as pharmacy benefits managers? (CNBC, Axios)

INDICATIONS

The drug price hike train keeps rolling. President Donald Trump predicted rapid, significant drug price cuts following his administration's unveiling of a blueprint with theoretical proposals for pushing back on high medicine costs. It's possible some of those will materialize at some point. Today is not that day. Pfizer, Seattle Genetics, Sanofi, and a host of other companies have continued the usual trend of raising prices mid-year. Some of the hikes this time around have been relatively modest compared to overall and medical inflation; Pfizer, however, is implementing an average 9% increase on more than 100 prescription medications—the second year in a row of significant price hikes despite ostensible political outrage on the issue. (Fortune)

Sanofi goes back to its basics. Sanofi has been grappling with tough times for its flagship diabetes business for about a half-decade now. Now, it's aiming to return to growth in its bread-and-butter sector, reports Reuters, with a planned revamped pipeline of drugs grown via partnerships and acquisitions in the coming years. (Reuters)

THE BIG PICTURE

Two states mandate mental health education in schools. New York and Virginia on Sunday became the first two states in the nation to mandate mental health education in schools, including middle schools and high schools. The laws' enactments on Sunday reflect growing concern about the state of young Americans (and the population's at-large) mental wellbeing amid rising rates of self-reported depression and suicidal thoughts among teens.

Can coffee really help you live longer? Another day, another positive coffee study. This one, led by the National Cancer Institute (NCI), finds that even the heaviest coffee drinkers and decaf drinkers have a relatively higher chance of living longer than non-drinkers (ahem, correlation does not equal causation). So what's up with all this glowing bean-based research? Is it hype or just wishful thinking? I break down some of the existing literature here. (Fortune)

REQUIRED READING

This Heat Wave's So Bad It's Even Slowing Down U.S. Stock Trades, by Bloomberg

Americans Rely on China for Their July 4th Celebrations, by Renae Reints

Bitcoin Futures Killed the Bitcoin Rally, Economists Say, by Kevin Kelleher

Fentanyl Is Causing Almost Half of All Overdose Deaths, by Brittany Shoot