It’s Norman Rockwell’s fault. The image of the gray-haired family physician, stethoscope in ear, patiently listening to the heartbeat of a porcelain doll as his young patient looks on, is indelible in the public memory.
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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