Jerri-Lynn here. During the pandemic, I’ve done some telemedicine sessions, but only with doctors I’ve seen in person before. So I don’t know exactly how I view this trend, especially as so many medical ‘innovations’ are more focused on making profits, at the expense of patient care. So what may seem to be a good thing in theory, on reflection turns out to be just another vehicle for profit extraction. Because that’s what our neo-liberal health care system is designed to do.
Readers? What’s your experience with telemedicine? What do you think?
By Julie Appleby, Senior Correspondent, reports on the health law’s implementation, health care treatments and costs, trends in health insurance, and policy affecting hospitals and other medical providers. Her stories have appeared in USA TODAY, The Washington Post, the Philadelphia Inquirer, MSNBC and other media. Originally published at Kaiser Health News.
At the height of the covid-19 pandemic, people often relied on telemedicine for doctor visits. Now, insurers are betting that some patients liked it enough to embrace new types of health coverage that encourages video visits — or outright insists on them.
Priority Health in Michigan, for example, offers coverage requiring online visits first for nonemergency primary care. Harvard Pilgrim Health Care, selling to employers in Connecticut, Maine and New Hampshire, has a similar plan.
“I would describe them as virtual first, a true telehealth primary care physician replacement product,” said Carrie Kincaid, vice president of individual markets at Priority Health, which launched its plans in January as an addition to more traditional Affordable Care Act offerings.
The often lower-premium offerings capitalize on the new familiarity and convenience of online routine care. But skeptics see a downside: the risk of overlooking something important.
“There’s a gestalt of seeing a patient and knowing something is not right, such as maybe picking up early on that they have Parkinson’s,” or listening to their heart and discovering a murmur, said Dr. David Anderson, a cardiologist affiliated with Stanford Health Care in Oakland, California. He said online medicine is a great tool for follow-up visits with established patients but is not optimal for an initial exam.
When enrolling in one of the new plans, patients are encouraged to select an online doctor, who then serves as the patient’s first point of contact for most primary care services and can make referrals for in-person care with an in-network physician, if needed. It’s possible patients never meet their online doctor in person.
Many insurers offering virtual-first plans hire outside firms to provide medical staff. The physicians may hold licenses in several states and not be located nearby. Insurers say participating online doctors can access patients’ medical information and test results through the insurers’ electronic medical records system or those of the third-party online staffing firm. What might prove tricky, experts warn, is transferring information from physicians, clinics or hospitals outside of an insurer’s network. Sharing patient information via EMRs is challenging even for doctors operating under traditional insurance plans with in-person visits — especially moving data between different health systems or specialty practices.
The virtual-first concept was so new that Priority Health called those enrolling this year to ensure they understood how it worked. “If people were more comfortable with brick-and-mortar, they should choose other options,” Kincaid said, adding that the plans have drawn 5,000 enrollees since January, a number she hopes will double next year.
Many insurers offering virtual-first plans hire outside firms to provide medical staff. The physicians may hold licenses in several states and not be located nearby. Insurers say participating online doctors can access patients’ medical information and test results through the insurers’ electronic medical records system or those of the third-party online staffing firm. What might prove tricky, experts warn, is transferring information from physicians, clinics or hospitals outside of an insurer’s network. Sharing patient information via EMRs is challenging even for doctors operating under traditional insurance plans with in-person visits — especially moving data between different health systems or specialty practices.
The virtual-first concept was so new that Priority Health called those enrolling this year to ensure they understood how it worked. “If people were more comfortable with brick-and-mortar, they should choose other options,” Kincaid said, adding that the plans have drawn 5,000 enrollees since January, a number she hopes will double next year.
Doctor on Demand launched in 2013, aimed at individual consumers. Starting with a Humana contract in 2019, it has since expanded to offer staffing for several other insurers. The company, which has its own electronic medical records system, hires a range of primary care, mental health and other medical providers. Physicians must be board-certified. Pay is partly based on how many patients they see, and there is no upper limit. Some want to work part time, for example, and many work from home.
In general, virtual-first health plans may carry lower premiums or provide such financial incentives as no copays for online visits. All boast that members can get appointments quickly, sometimes within minutes. Patients with serious problems are assisted in arranging emergency help. If online physicians determine patients need a blood test, immunization or a visit with a specialist, they refer them to a local practice, clinic or specialist within the insurer’s network.
As a strategy to contain costs, think HMO 2.0.
“There’s more control over the patient interaction and where they get referred,” said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
Still, patients should be aware that some of these plans may allow a brick-and-mortar visit only if their virtual doctor, who may have never examined them in person, deems it necessary.
Skeptics note that many circumstances demand in-person care. One recent study estimated about 66% of primary care visits required it. For example, it’s impossible to check reflexes and difficult to examine tonsils for infection virtually.
Patients in some programs, including Harvard Pilgrim’s, are sent kits that can include devices like blood pressure cuffs and thermometers — though at-home medical measuring devices are often not as accurate as those used in offices. Online physicians may also ask a patient to feel for swollen lymph nodes, shine a light into their throat while on camera or take other actions to help the physician diagnose a problem.
Kincaid, at Priority Health, noted that Doctor on Demand also sets protocols on children’s wellness visits, which it says must be done in person.
“It’s important for children’s wellness visits to get accurate height and weight measures and immunizations,” Kincaid said.
When considering virtual-first plans, advocates say, patients should look closely not just at premiums but also at deductibles and copayments, which may be set at levels that discourage in-person care. Rules are varied and dizzying.
The VirtualBronze plan offered through the federal ACA marketplace in parts of Texas by Community Choice Health, for example, requires hefty patient contributions for many types of in-person visits.
Patients incur no copay for using online Doctor on Demand physicians for primary care visits or for accessing in-person preventive services as defined by the ACA, such as immunizations or cancer screenings. But for other in-person services, Community Choice’s virtual plan will cost patients out-of-pocket because they pay the cost of the care until they meet an annual $8,530 deductible.
Kaiser Permanente’s Virtual Complete plan offered to large employers carries no copay for online care. Patients can opt to see an in-person doctor three times a year for primary care if they’re willing to pay a copay. After those three visits, any additional in-person visits are subject to a deductible.
Plans sold through federal or state marketplaces and those offered by employers must meet the ACA’s requirements. That includes a range of services, from doctor visits to hospital care.
Corlette, at Georgetown, said consumers should be wary of plans that are not ACA-compliant.
She fears the advent of plans that give patients “access to online providers, but nothing else.” And that, she said, “would not be considered major medical insurance.”
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Younger people involved in virtual care for mental health have expressed strong interest in expanding that option.
They have told me that their generation is more comfortable with online interactions and less inclined to want to visit facilities for routine matters.
They also like the prospect of more young people getting access to treatment during initial phases of what might turn into more serious matters. That access overcomes hesitation to visit, whether due to preference, pandemic or other factors. It should lead to broader care and earlier intervention, as needed, and reduces the population of the undiagnosed or untreated.
Obviously, many mental health matters need in-person diagnosis and treatment, but not all of them.
This goes back at least a year, but I had a conversation with a relative who is a family doctor, and shortly after with a friend who is an emergency room consultant. The former felt that telemedicine was working quite well with some patients, but the ER doc was complaining at the huge number of new patients been sent to emergency rooms by local doctors as a precaution following a ‘remote’ consultation.
I do not have a smartphone or a computer with a camera so my insurance company, which wants to push telehealth to me, has few options. I did do a phone health visit in 2020 but it was a waste of time. I am sure the insurance company is merely trying to maximize their profits. This last year I did not do one and will not do one in the future as they are useless.
I do enjoy the standard question, “Have you, in the last year, felt depressed, sad, or considered doing yourself harm?” I like to reply that I have experienced fleeting moments of hopefulness but they soon pass.
I’ve had pretty good experiences with tele-care, both mental and physical, but I have good relationships with my doctors by and large.
Want to know what I think? I think health insurance is fraud. Change my mind.
I immediately think of this experience my wife and I had.
My wife was having awful, sustained, multi-week periods with horror-movie bloodflow. We went to her primary care physician, who looked at her, talked with her, and prescribed ibuprofen. The physician never touched her. The disabling periods (she was getting near to fainting, was bedridden for days) continued.
Finally we went to a OBGYN. This physician felt my wife’s abdomen, and IMMEDIATELY said “We’re scheduling you for surgery ASAP” and got on the phone to do it. The (non-cancerous) fibroid tumor that came out was the size of a softball.
Telemedicine would deliberately miss this.
Whew! I hope your wife is feeling a lot better now.
Telemedicine would have had the same result if it had been your primary, but agreed, specialist doctors in many instances cannot do there job virtually
I’m going to venture that this might be easier to implement post Covid due to physicians’ ability to obtain temporary licenses to work all over the country. (Hi docs, what do you think?) I had a specialist here that I have parted ways with because he only checks into the office twice a year. Keeps an infusion room running and doesn’t even meet with patients remotely, has no doc on call. (I looked it up, he last had 6+ temporary licenses.) And thanks, Obama, for those massive dollars spent on EMRs. Those are, from what I’ve experienced, always terribly inaccurate. So, here we’ve got a new patient, perhaps inaccurate medical records, what could possibly go wrong? Well, I don’t think it matters.
I suppose telemedicine is ok if you know the doctor and it’s very limited, but I hate it. I agree that a patient needs to be properly examined and it can’t be done this way; this is just another opportunity to squeeze as much money out of an already horribly unequal system. Another HMO scam indeed.
And remember! You’re bound to arbitration in most jurisdictions. So imho, despite the weeping and wailing about tort reform, the corporate medical machine is in its usual all powerful position. Let’s say you do manage to make it to court, despite arbitration provisions, with caps on recovery (CA, at least) you’d, better have an airtight case. Because you’re worthless if you’re old and/or not working. And this isn’t free universal coverage where you’d be willing to give up some rights for that coverage. This is “coverage” people go bankrupt on.
So when I say “what can possibly go wrong?” with this insane telemedicine scheme, absolutely nothing- for the schemers. I guess I’m in Slim’s camp on this.
1. Large potential for interstate practice. Not sure what the rules are for licensure. Does the provider need a license where she is? Where the clinic is? Where the patient is? Could trigger a race to the bottom in licensing if the wrong answers. What if the provider is offshore?
2. Internet mediated visit means AI is spying and learning. The human providers will likely be more tightly scripted (as hinted at in the ear tickle by the reference to controlled referrals) and ultimately lead to bot medicine.
3. It’s not like we have primary care providers anyway. As questa Nota wrote, at least this way people can actually get some advice. Even if the advice is colored by someone’s financial interest.
Good point about offshore, EK, since much is done already out of the country. Dictation, X-ray interpretation etc. Anything to make a bigger profit. I’ve been wondering about these provisional and temporary licenses. Hospitals were bailed out. Who pays these temporary doctors, I wonder?
Why not? We’ve already got virtual medicine. How much worse can it get? One day we’ll be able to do all of our own lab work and maybe even 3-D print our own drugs. The medical profession should take note – this could literally make them obsolete.
How much worse can it get? Zoom tracks, records and sells all information that you give via the video, geo location and voice information on a specific call. All the data goes through foreign servers (China and perhaps other places). Perfect venue for voice print and recognition – a more accurate identifier than fingerprints and perhaps more accurate than DNA testing. Everyone’s voice is quite distinct. “Call In Centers” have been recording and using voice prints for quite a while and now everyone is getting on the band wagon: google; amazon; police; insurance companies; microsoft, etc. That information and those data points and identifiers are sold and shared with data bases all over. With voice recognition (not even getting into facial recognition) corporations and governments can assume or derive information such as: income; racial assumptions; educational background; depression; mental state in general; smoker/non smoker; optimism or lack thereof; and on and on. One example ….. these data points are sold to the airlines who then base the price of your ticket to Paris calculated upon these data points and “assumptions”.
More data points to be stolen and sold …… on you. That’s how much worse it is – much less how worse it “can get”. Cheap now but you’ll pay later.
“Your call may be recorded for training puposes” – They don’t tell you it’s for training their AI software.
I’ve been seeing a therapist for a couple of months, by video due to the pandemic. Now that vaccination and quality masks are available, I asked about meeting in person but he demurred. My suspicion is that he no longer maintains an office which for a therapist in individual practice is a big expense.
He also has his cell phone on during the session, not too subtly when it buzzes. He usually doesn’t respond but does look at it out of the corner of his eye. The whole scene borders on comedic.
I think I will move on. It’s good to have someone to talk to but would prefer to have someone who is fully present.
As a Kaiser patient, I have complained about their Health Connect privacy policy:
https://healthy.kaiserpermanente.org/privacy
5. Re-targeting
“We have contracted a third party ad network to manage our advertising on other sites. Our ad network service provider uses cookies, Web beacons, and other tracking technologies to collect information about your activities on this and other websites and to then provide you with KP advertising on other websites. We may also place a persistent third-party cookie (provided by Google) on your hard drive if you sign on to kp.org. This cookie will prevent kp.org members from seeing advertising that is targeted towards people who are not members of Kaiser Permanente’s health plan, when searching on Google.
If you wish to not have this information used for the purpose of serving you targeted ads, you may opt out. Please note this does not opt you out of being served advertising. You may continue to receive generic non-targeted ads.”
The opt out link simply doesn’t work for the majority of third parties listed at NAI (Network Advertising Initiative). I could follow a cluster of third parties that connected to the first party as I browsed. Never mind whether ads are targeted or not. Who knows what happens to third party data connected to my IP address, the Kaiser Permanente EMR portal and my browsing behavior. Is it used to profile?
Thus, I have opted out of their EHR.
Earlier this year, I made appointments that were encouraged as telemedicine. That included a PT appointment to evaluate what eventually was diagnosed as frozen shoulder/adhesive capsulitis in person at an outsourced clinic. (Kaiser wouldn’t for the most part accommodate patients with in person visits.) An initial PT evaluation by telemedicine? No way, regardless of privacy/security concerns.
As for other appointments this year, they were easy to address through telephone visits.
Eventually, I believe these appointments will come with co-pays at Kaiser.
Covid was the telemedicine behavioral nudge needed for Silicon Valley entrepreneurs and big data miners, who have been pushing this for a while. Convenience and safety comes with a price IMO.
Well, I’ve not received any tele-medicine recently (ever). But I can imagine that most of one’s time will be taken up with nurses and other assistants other than the doctor. Will I be self-reporting my pulse, temperature, and blood pressure? Will any video connection be vibrant enough to discern pale skin, redness in the eyes? Will the voice quality detect a raspy throat?
Will I be put on “hold” until the Doc has time to make a diagnosis? Is my 15 minutes of professional attention reduced to 10 minutes? Will there be a reduction in fees? How does it improve medicine delivery.
Yep, you report your vitals to a nurse in a pre-screen call. This is pretty much like an in-person visit where the nurse comes in and takes your vitals before the doc comes in.
My doctor is great, he doesn’t try to rush through a visit. I’ve found it works well for a routine check-in kind of appointment where there’s no exam needed.
I’ve had telephone calls with the doc (I refuse anything else electronic). Useful in a pandemic but very limited of course. Kind of like taking out a loan. You can get a loan from the bank only if you don’t need one and a tele-visit is really safe only under the same circumstance.