What could go wrong?
Ever since the Federal government began encouraging health care providers to adopt electronic health records a decade ago, Apple, Google and a slew of Silicon Valley startups have sought to bring about their own vision of telemedicine—turbocharged by data from wearable health-monitoring devices, artificial intelligence and smartphone apps. Apple’s bio-monitoring watches and Fitbit, the wearable exercise monitor recently bought by Google, are two prominent examples of products in the market now. Other companies are readying artificial-intelligence products that could augment or replace advice from medical professionals.
There’s a big difference, of course, between shopping for a new desk lamp and seeking medical advice for abdominal pain. The prospect of app-based health care raises many questions. Can online services really do as good a job in meeting many needs as the traditional pilgrimage to the health-plan-assigned doctor and clinic? Will people who distrust Facebook and Google for abusing customer data willingly vouchsafe their private medical records to another tech giant? Should they?
Digital medicine
Patients seem amenable to telemedicine, whether by video, voice or text. In fact, one out of five patients insists on a doctor willing to do some sort of remote consultation, according to a 2017 Harris poll, while a Rock Health Survey found patient interest in telehealth nearly doubled between 2017 and 2018. Some large health care providers have responded. At Atrius, more than half of the encounters between its 740,000 patients and 715 doctors now take place through some form of electronic communication. The University of Utah’s medical center is another pioneer, offering a wide range of telehealth services to all its patients. In a study of 200 pregnant patients the university found that offering telehealth nearly halved the number of face-to-face visits during the pregnancy, cut costs substantially, and raised patient satisfaction from an already impressive 97 percent among face-to-face-only patients to a perfect 100 percent among those who used telehealth. “It improves patient engagement in their health,” says Maia Hightower, the university’s chief medical information officer.
The Veteran’s Affairs Department, meanwhile, has provided more than 2.6 million telehealth interactions to nearly one million veterans, about 100,000 of them having engaged in a video consultation. The services have been especially valuable to the 30 percent of VA patients who live in rural areas far from VA hospitals, as well as providing the more frequent monitoring and care required by those with diabetes, heart disease, and other chronic diseases suffered by 60 percent of all Americans and 85 percent of older Americans. “We can do more online to help control a patient’s high blood pressure or diabetes by talking to them about their meds than we can by putting our hands on them,” says Dr. Leonie Heyworth, director of synchronous telehealth for the VA. Video patients had 28 percent fewer missed appointments than in-person-only patients, Heyworth added.
The resistance
Most U.S. health-care providers and insurers are resisting the move to include telehealth options. Instead, they’re sticking to the tried-and-true business model of getting patients to come into a relatively nearby office or hospital and charging handsomely for the privilege—even though patients rarely know exactly what those costs will be. In large part that’s because for all the concerns about U.S. health-care costs, most private hospitals and health-insurance companies are doing just fine financially. Why risk the leap into a lower-cost, less-familiar style of health care? “In the current health care world, the only way you’re going to get paid is by having the patient come into the office, even if that’s not always going to lead to great care,” says Atrius’ Strongwater. As a result, fewer than 15 percent of U.S. physicians offer telehealth consultations, according to the American Telemedicine Association’s Johnson.
What health insurance companies, as well as employers who foot the bulk of the U.S.’s health care bill, especially fear from telehealth is that it’s so easy to use that people will reach out more often for care. “It creates the risk that every little ache and pain results in a claim that has to be paid out,” says the University of Pennsylvania’s Asch. “Making people come into the office is health care rationing by inconvenience.” Even Medicare currently won’t reimburse for most telehealth services. And yet almost all doctors and experts agree that getting people to check in more often, more cheaply and more conveniently with their health care providers would almost certainly lower total costs by giving providers more opportunities to catch problems earlier when they’re easier and less expensive to treat.
While providers and insurers seem stuck on the status quo, patients are losing patience. The HealthPocket survey found that more than half of adult Americans have skipped medical care to avoid costs, and some have presumably done so to avoid the inconvenience of an office visit. Employers are equally eager for a fix, says Fontanetta, who heads up strategic growth for Willis Towers Watson’s North America health care practice. Not only do employers on average pay upwards of $10,000 a year in health care costs per employee, notes Fontanetta, they’re seeing annual costs for employees with cancer and other complex diseases rising at double-digit rates from an already astronomical $50,000 a year, making them the biggest source of health care cost increases. “There’s a big opportunity to use telemedicine to reduce those costs by linking individuals with world-class care outside of their local area to get more accurate diagnoses and more effective treatments,” he says.
The Apple Watch, for example, is already FDA-approved for diagnosing certain irregular heartbeat conditions. And Verily, the health technologies venture mostly owned by Google’s parent company Alphabet, has in partnership with medical-device maker Dexcom developed a glucose monitor worn on a diabetic patient’s skin. A companion phone app prompts patients who wear the monitors to take pictures of their meals and snacks, enlisting AI to recognize any of a million different foods. “That provides a visual association between what people are eating and what those foods are doing to blood sugar,” explains Vivian Lee, Verily’s president of health platforms. Lee adds that the information can not only help nudge patients into healthier eating, it enables health coaches and clinicians to provide more effective guidance and interventions via text or tele-consults.
Consumer concerns
For all their complaining about the high price of U.S. health care, consumers are in many ways spoiled by its money-is-no-object approach to treating patients. They’re used to running to the doctor’s office or even the emergency room when they feel they need to, and rarely think about shopping for the best deal, other than making sure their provider is in their health plan’s network. They also expect to get the most effective treatment available, even if another treatment might work nearly as well at lower cost.
They’ll also have to get used to the idea of making more of their health care decisions, as well as having some of their health problems solved, via text messages, apps and websites. Many older patients may have trouble making the leap, notes Fontanetta—which means it will be up to younger people to pave the way. “Millennials and Gen Xers already prefer virtual interactions,” he says. “The way they access health care will likely track with all the other virtual ways they buy goods and services and communicate with others.” Jay Sanders, CEO of the Global Telemedicine Group, a health care management consultancy, agrees that the transition to a telehealth-first system will be in the hands of a new generation of patients. “The speed of adoption will be set by how quickly younger people come to see it as routine,” he says.
Ironically, patients who do switch over may actually find it easier to share their health problems with their electronic providers than they do with the human versions. “When a doctor asks you how you’re doing, a lot of people have a tendency to say ‘fine,’ even if they’re not,” says Priyanka Agarwal, a physician who recently left the Center for Digital Innovation at the University of California San Francisco to head up digital health at MyoKardia, a biotechnology firm focused on heart disease. “There might be hundreds of small signs of problems that patients don’t know how to communicate in a face-to-face meeting with a doctor, but that a monitoring device or a software program can pick up on.” Such signs might be anything from minor aches to trouble sleeping to bouts of fatigue.
No one thinks human care is going away, or even that it necessarily will be reduced. But under new, more electronically driven health care systems it may be redistributed in a way that reduces costs and improves outcomes. “Everyone in the system could get all the digital touches they need all the time, because they’re so easy to scale,” says Utah’s Hightower. “That way we can give more of those higher-cost human touches to the higher-risk patients, even up to sending clinicians to their homes.”
Hey Alexa, I need a house call. Disruption is on the way.
