Telemedicine Tales

Yves here. A few months back, I described my Luddite biases about telemedicine. On the one hand, the idea of allowing established patients to consult with an MD outside an office visit is a big plus. Even before getting to Covid-19 concerns, it saves patient time and hopefully allows patients whose work or family demands makes it hard to free up time during normal office hours to get treated. On the other, the US being the world capital of rentierism, it isn’t hard to anticipate that telemedicine will often provide lower service levels with no corresponding price reductions.

Below, we feature a post by a clinician who confirms our concerns. He had advocated telemedicine in the pre-Covid era. He warns that telemedicine is creating cookie-cutter by design “doc in a box” practices, for instance restricting participating MDs in the tests they can run.

It had not occurred to me that the telemedicine services provided to MDs would be anything more than established MDs consulting with patients by phone, as they routinely did in Australia in the early 2000s, and/or getting a secure videoconference line. Earlier this year, in Alabama, my mother’s crusty MD reluctantly did her annual exam by phone. But my regular doctor in New York insisted on video (I needed an office visit for her to consider giving me a new scrip), claiming it was necessary to be “HIPPA compliant.” That made me wonder if she thought she was required to retain a recording. I didn’t find that acceptable (I also generally hate videoconferencing with the passion of a thousand suns) and flew to New York instead (yes, I am insanely protective of my medical privacy).¹ This discussion of the tech of telemedicine makes me think I am less nuts than I did before.

This post doesn’t acknowledge another pet peeve: in Australia, telemedicine in the form of phone consults for established patients was well established. It was also understood to be a supplement to office visits, not a substitute for them, and priced accordingly.

Due to Covid-19, CMS mandated payment parity for telemedicine visits. This is unfortunate since for some, perhaps arguably many types of concerns, a telemedicine session simply cannot allow for as much diagnosis as a live visit. The doctor cannot listen to your lungs and heart, stick a light in your ear, see your skin color accurately, poke your belly if it needs poking, or examine body parts that are not behaving normally. And if the doctor provides a treatment, it would seem probable that at least for some patients, the placebo effect would be reduced.

In other words, a practice that ought to be a boon looks set to become a vehicle for crapification. And the US medical system is pretty crappy to begin with.

By Cetona. Originally published at Health Care Renewal

1. Introduction. This post might just as easily be entitled “tales from the crypt,” so far down the netherworld chute have American public health and medical workers been plunged. Nowadays whenever I speak to fellow physicians and tell them I’ve moved on from my own front line patient care, we exchange these utterances: they say “congratulations, I’m envious” and I say “my condolences.” But the topic for today is more focal: telemedicine in the Age of Coronavirus.

Telemedicine, or “telemed,” doesn’t quite fit neatly into my ongoing series on why my dander’s up. So for now let’s set it aside and come back another time. It turns out that telemed—remote diagnosis and treatment using telecoms—is, like so many other innovations in health care, a two-edged sword. Let’s look at it and see if we can come up with provisional answers to what, exactly, it means, beyond fear of face-to-face, to see its use soaring these days.

I’ve observed telemedicine now in a number of settings—lots of testimonials from colleagues, family, friends, and in just one instance myself as patient. Most of this is quite recent, for reasons we’ll get to. I’ve never practiced it, never had time on my schedule to Zoom into some patient’s bedroom. That’s just an artifact of the timing. But I used to teach about it. And now it’s arrived like gangbusters after languishing for decades in the ever-hopeful hearts of long standing organizations (here, here) devoted in part or in full to digital medicine.

The “why” for this onrush of telemedicine exposure is an easy one. In the Before Times, we had reimbursement problems that impeded it. All the other barriers, by, say 2010, were secondary. All our clocks now have a thick black line between BC and AD. Before Coronavirus versus After Donald.

Back in the BC, we can’t get it paid for. Now, in the almost-AD: HHS rushes out new emergency regs, enabling telemed. With the pandemic, the new regs arrived just when providers, deprived of adequate PPE and in some cases a big chunk of salary, really needed the option. Whether they actually approved of it or not, different story. Necessity is the mother. All the rest is dross.

The above remarks set the stage. We just need to remind ourselves in passing: there’s just not much scientific evidence for this technology’s safety or efficacy. Rather, like so much else in digital medicine, telemed is probably here to stay because of one or another regulatory or epidemiologic crisis. Contrariwise, it’s not an evidence-based imperative, at least not with respect to clinical results. For providers, of course, it may well mean survival, a different story.

So until we get more convincing science, here, for this blog’s intrepid readers, are some narrative bits and bites to chew on: telemedicine, the good, the bad, and the ugly.

2. The Good. The single telemed session I undertook as a patient, reviewing some physiatric maneuvers, went rather well. So, too, did a family member’s. When teaching about telemedicine I used to fret to think about its lack of touch. A cardiologist recently related some of his difficulties he’d had—the need to evaluate heart and lung sounds, to feel the liver—and how he recently almost lost a patient by relying on telemed. In that case, the common dreaded complaint of “I’m so tired” proved to stem from complete heart block. But this cardiologist didn’t diagnosis his patient’s CHB by telemed. He did it when he had the good sense to send that patient to the ER.

Conversely, I watched a vertigo patient properly and fully worked up, including appropriate neurologic testing. Vertigo is so often of the benign positional variety that this all made sense, with discussion of all the diagnostic and therapeutic maneuvers, the extensive taking of a history that can nail some diagnoses, and discussion of follow-up. There are lots of instances where such outcomes are possible. Physical therapy is another area where a session may go quite well.

Then, still in the “good” column, there’s the public health benefit. An Associated Press release about telemedicine and coronavirus in Florida recently—this was late August—underscores the benefit. The AP release, available widely, e.g. here, didn’t seem to get a lot of traction beyond its own republication. Maybe it was just drowned out by late summer vacation blues, gladiatorial politics, and whatever other Daily Outrage we’re all lately subjected to.

In a relatively underserved area of Jacksonville, the site (or one site) of the GOP Convention days earlier, an aging public health nurse, like so many health workers faced with COVID-19, had a telemed session with a family physician, Dr. Cain. Both belonged to a minority community especially hard hit by the virus. Which is to say, hard hit by recent Florida politicians’ methodical dismembering of the state’s public health infrastructure. Privatization is one causative element of the systematic down-rating of public health in places like Florida. Ideology is undoubtedly another. Poor people’s bodies are a favorite target of budget-cutters. They really don’t matter, right? So those bodies get thrown under the bus. Always were.

Telemedicine can be a boon to the underserved, a patch on our deficits in social justice and public health. That was the case for Ms. Wilson, Dr. Cain’s patient, who received assistance and did well. In the right hands—largely, I’d say, telemedicine offered by academic health centers (AHCs), but also in community hands such as Dr. Cain’s—it can make a difference in narrowing the gap. Further, lest we view this as somehow second class, many patients in all socioeconomic categories prefer it—see the next section below—to going in and sitting around in waiting-rooms at either AHCs or community clinics.

3. The Bad. That’s true even in the best of times. But as we know, right now we’re not in those times.

On to the bad and the ugly. For the reader’s consideration I submit a recent report (personal communication) from a colleague—a highly educated and sophisticated tech CEO—who’d enrolled as a patient in one of those “with six you get egg roll” deals with a telemedicine start-up. Right now a great number of telemedicine providers are based on free-standing start-ups: I know this because on a daily basis I receive at least one entreaty from such companies to throw my own hat in their ring. (Which was damned tempting by the way.) I’ve lost count, and I wonder whether there’s any way to count up the entities that provide which kind of care. If there is, please add a comment below and tell me where that study’s to be found.

Meantime, let’s just put out there a typology—then let me how many of each you think there are.

1. Academic centers’ operations, now rampant, and generally fairly good (or as good as Zoom), in the AD time of coronavirus
2. Dr. Cain’s operation and other, similar, community-based ones (private/small group)
3. Start-ups, which might or might not be conceived as extensions of physical docs-in-boxes

You tell me. Meantime, having talked to a lot of providers and patients who earn, or save, cash by participating in the doc-in-a-box style telemed shops, I’d like to tell my tech confrere’s tale. Actually, let me let him tell it in his own words, substituting StartUp for the particular telemed company name.

I was overdue for my yearly physical, and since I had a subscription to StartUp, I decided to use the telehealth service for my physical.  I didn’t have any major complaints, but I wanted to get some routine labs taken to make sure all was well.  I fired up the … app and after giving a brief description of my concern and a few minute wait, I was virtually face to face with a doctor.  I’ve been on Propecia in the past, and have recently started it again during the COVID lockdown.  I knew my family physician often ordered a PSA test while I was on Propecia, so I thought it would be prudent to ask for the lab to be included in my blood work.  Things didn’t go so well.

Me:  I’m on Propecia, and I know my family doctor often ordered a PSA test in the past, can we include that?

Doctor:  What’s Propecia? 

Me: It’s Finasteride.

Doctor: Is that something your doctor prescribed?

Me: Yes.

Doctor [emphasis added here and below]: Well, they don’t like us to order labs that require followup, so… 

Me: OK (I figured at this point it wasn’t worth arguing the finer details of [StartUp] policy and I was reasonably sure the PSA would have been normal)

Doctor: I’m ordering the labs, but sometimes they don’t go through, so if there’s a problem, just contact support and they’ll sort things out.  Also, don’t forget to follow up once you get the results.

OK, so other than not knowing what Propecia is, not being able to order the PSA test and the fact that none of the tests might actually have been ordered, the call went pretty well. 

I made an appointment with Quest Diagnostics through the … app for early the next morning to have the blood drawn.  After arriving at Quest and signing in, I was told there weren’t any lab tests that had been requested for me.  I was prepared for this, and showed the receptionist the StartUp lab order PDF.  She looked at it and quickly said that they couldn’t accept this as the order didn’t include the doctor’s name and she wouldn’t know where to send the results.  I left, went back to the car, launched StartUp and requested another virtual consult.  After explaining to the doctor what Quest told me, he said it was strange but that he would re-request the labs.

Armed with the new lab request, I went back to Quest, and spoke to the same receptionist.  She noted that it looked like someone “had done something” but there still weren’t any lab tests to be found.  She also noted that their systems “weren’t connected to anyone else”.  At this point, I pushed back as I was fairly certain the lab tests were lurking in the Quest system and it was possible that the receptionist just didn’t have experience or training with StartUp lab orders.  After some back and forth I was able to get her to enter the number provided with my lab order and was cleared to get the test.  As an added bonus, the Quest receptionist incorrectly told me that my insurance had been cancelled, only to later realize that she had entered my ID number incorrectly.-

This was on a Friday, so I expected I would receive results early the following week.  On Tuesday I received a notification that my labs were available in the Quest portal.  I checked out the labs and then opened the StartUp app to initiate a follow up call to review the results.  Only one problem, according to StartUp the labs were still pending.  I sent a message to StartUp support and they said that normally results are available in the app as soon as the lab has them and that they would work with engineering to figure out what had happened.  Twenty=four hours later, there’s still no word from engineering and the labs are still listed as pending in the app.

I am lucky enough to have a distinguished physician as a friend who was kind enough to look over the labs and give me the all clear.  Without this connection, I would have been left wondering about the results and given that the StartUp doctor didn’t seem familiar with Propecia (a common medication), I’m not sure I would have fully trusted their evaluation of the results.

It’s no wonder that people who go to doc-in-a-box (or NP-in-a-box) sites typically do so for only the simplest and most straightforward complaints. And it’s no wonder that the venture and hedge funds that capitalize these outfits do so in many cases while advertising they focus only on high-yield, low-risk diagnoses such as erectile dysfunction and contraception. Maybe the odd UTI or URI.

Oh, and colleagues who work for them tell me they exercise all sorts of mind-control, telling the providers what to say and what they can’t say. Sadly, docs do this stuff (in category 3 above), often to moonlight and they just swallow their gall. Easy enough on the ‘net to find out, however, exactly what they think about working for these outfits. But how many patients buy into it, as my colleague did, not knowing all this background?

In so many cases, therefore, it’s all just another golden exercise in American ingenuity and lapping the cream. In no way is it, in its free-standing version, a response to the challenge of improving health care. Rather, it’s the usual and sad response to improving investors’ wallet contents.

4. Footnote: the Price of Admission. You can’t do telemedicine without a good connection. But many who might most advantageously avail themselves of telemed consultation don’t have that adequate connection. For those who’d like to read more about this conundrum, Brookings has just published a Techtank blog, by Visiting Fellow Tom Wheeler. He offers useful solutions in a piece entitled “broadband in red and blue,” with some concrete and hopeful ways of redressing what’s essentially yet another AD (After Drumpf) problem: the way the US has been closing the Digital Divide more assiduously for red than for blue states. The challenge, per Wheeler: “[t]here are almost three times as many Americans without a broadband subscription in blue urban areas than in red state rural areas.”

People currently thinking about back-to-school issues, and kids’ telelearning, probably aren’t thinking quite as much about telemedicine, despite the striking parallel. But they should Beforethey get sick.

The problems of telemedicine mirror those of the larger society, as does health equity mirroring societal equity. This will come as a surprise, no doubt, to precisely no one. Let’s hope after November we get to putting the solutions, and the promises of telemedicine, into more socially just practice.