Telemedicine has become a word associated with fragmentation of care. This is largely because the national telemedicine companies (Teladoc, MD Live, American Well and Doctor on Demand), known as the Big Four, have used staffing models that pair patients with unaffiliated physicians for one-time-only phone or video encounters. This is not to say that conceptually remote doctor visits are flawed, just that the current approach taken on by mainstream telemedicine disrupts continuity between a patient and their home medical system – even if, in the greatest of ironies, that system is paying for the encounter to occur.
Logic would suggest that medicine will follow other industries toward a remote communications-based model in the not-too-distant future. The transition away from fee-for-service medicine will cause doctors to want to deliver value and improve outcomes for patients without requiring them to travel into the office for every touch point. Payers are onto this, but to date have only had one general form of telemedicine to offer to their members, the Uber-like model in which a detached physician with spare time is paired with a patient for a brief consultation. This model is universally saleable to organizations with members in multiple states because of national telemedicine companies’ centralized grid of doctors stationed (or licensed) in many states. But all health care is local. In order to localize telemedicine, and integrate remote care with physical care infrastructure, added layers of complexity and new modeling are required.
Teladoc went public in 2015 with around 10 million subscribed members and a utilization rate of under four percent. Investors were happy to buy stock in the company because they appeared to save money for their clients and the market believes remote care makes sense. The problem is that it’s not entirely clear how much money is saved for clients of national telemedicine. One shortfall of the Big Four model is the high cost per visit if a particular program fails to achieve sufficient utilization. To simplify, if a company with 100 employees is charged $1 per employee per month for access to a remote service and only two employees use the service, once each during the year, each of those visits cost the employer $600.
Utilization is the key factor for driving down the cost-per-visit on a subscription model. So how do you drive up utilization? Many companies have tried to crack that code but only a few have begun to succeed. What we’ve learned from lower-than-expected uptake of telemedicine delivered on such modeling is that the missing ingredient for success is an ongoing relationship.
A recent article in the New York Times rightly highlights that the promise of telemedicine is based upon what doctors actually can do for patients if a contextual framework is set for them to deliver value remotely; said another way: if decreasing utilization of high-priced resources becomes profitable for the doctor. This is the case in many large care delivery systems today that align physician’s incentives with the overall mission of the organization: to improve outcomes and patient experiences while decreasing costs. Physicians in integrated systems are aligned with the health plan and are increasingly empowered to practice without economic pressure to run up charges in a fee-for-service model.
What’s needed is a context in which the physician can influence the patient’s course of care, follow up, and keep in touch. This is what’s been happening for one of our clients in Texas, where over 2,000 employees have had access to an emergency physician through CirrusMD since mid-2015, leading to a utilization rate that peaked during flu season at 22 percent.
By fully integrating with their patients’ health records and allowing doctors to easily stay in touch with those patients over a period of hours, even days, CirrusMD is facilitating a relationship between the patient and doctor which allows for a level of communication and continuity that’s more valuable than a physical exam in many cases. This level of communications, combined with the transition from fee-for-service to a value-based care economic model is expected to reduce in-person visits by as much as 50 percent, particularly in expensive “unscheduled” venues such as urgent care and the emergency room.
The best kept secret in clinical medicine is how much value a physician can deliver to patients if the economic arrangement doesn’t require the doctor to have the patient show up to the office. Given what doctors are capable of, providing the right kind of virtual care environment can actually increase touch between a patient and their doctors. In most of modern medicine, communications are more important than the laying on of hands for closing the loop and improving outcomes.