Worsening Costs Quality and Access with Telehealth

It has become common to promote innovations as solutions without sufficient testing and without really considering the possibility that the intervention might not work as planned. After decades of failure to resolve cost, quality, and access woes across medical error focus, managed care, managed cost, EHR/HIT, PCMH, alternatives to physicians, insurance expansion, and numerous forms of Pay for Performance - the cost, quality, and access problems remain. Telehealth deserves to be critically examined as a solution for rural or underserved populations.



First of all, telehealth will be priced in a way that supports expensive medical personnel, managers, CEOs, and investors. There is no intent for service for those low or no pay or with worst insurance. This will require payment.

Medicare and Medicaid patients will play a major role as they are concentrated in places with lowest concentrations of physicians. Indeed this is a major reason for shortages. These are the places receiving lower payment for the same services in a number of dimensions. Arguably these are the highest value settings. These are settings that have not been given the chance for higher payment across the past four decades. How Can CMS Improve Value In the Most Valuable?

Why not invest in the most valuable rather than a new innovation that will cost more and is not really focused upon access, cost savings, or quality?

Costs

The costs of health care must increase because of telehealth. Someone has to pay for the equipment, personnel, connections, security, and more. 

As with convenience clinics, there will be utilization increases.  This occurs due to the telehealth visit and also as a result of the telehealth visit.

Much of what telehealth can do is pass on the patient to another health care provider. There will be claims of saved lives, but frankly there is no way to actually tell what would have happened. But there will be patients referred for additional care and costs and consequences.
From TeleOutreach or Teleprofiteering - The Ecology of Medical Care considers 1000 people and about 800 a month have some health concern or symptom, 327 think about seeking care, and 217 visit an office (half in primary care). Those who think about profit all waking hours know that they can exploit about 30 more visits from each of three categories - those who have symptoms, those who think about a visit, and those who visit an office. 
The potential is to have as many visits from telehealth as seen in primary care. At $50 - 100 dollars a televisit for hundreds of millions in additional visits a year one can see the attraction to those who devote their lives to profit.


More patients will go from those with minimal symptoms, more will go from those thinking about going for care, and more will go from those who seek care. 

 The potential for profit is high with expanded coverage of telehealth services to Medicare and Medicaid and other populations less health literate and less able to navigate the complexities of the care system.

Outcomes
Outcomes will not be improved. Outcomes are not about clinical intervention. Outcomes are about the patient, local, and community factors. Telehealth does not impact these areas and indeed may erode them.
  
Colds and Bronchitis - Americans already access too many antibiotics, often for the possibility of saving 1 day of symptoms in a 10 - 11 day session of illness.

Urinary Symptoms - 70% of the women getting antibiotics will not need them and those who have sexually transmitted diseases or cancers or hormonal reasons for their urinary symptoms will not have a culture or urine test or follow up to state otherwise. 

 High Fever - High fever is a complex medical condition that continues to test clinicians that have full access to the patient and family as well as basic tests.

 Access

 Access barriers will remain. Those in most need of access will not even be able to access telehealth. Accessing prescriptions when needed will also be a problem - a much worse problem since mail order pharmacies and lowest payments for small or independent pharmacies have been depleting pharmacy access. The mail order impact upon local pharmacies is a relevant example to consider regarding the impact of telehealth upon local primary care.

Health literacy and internet literacy fail where access fails because workforce receives too little payment for the costs of delivery too high and accelerating.

Access barriers will likely worsen. Primary care depends upon a mix of underpaid complex services and overpaid simple services. Telehealth will steal the simple dollars that do not require time and team members, leaving the greater challenges for local primary care.

Missing the Complexity of the Interaction

 Telehealth is single problem focused and misses the mark addressing patients with multiple areas to consider and multiple areas to address. 

Telehealth is less likely to focus on preventive care, chronic care, or caregivers. 

Telehealth is not going to have a thing about making sure that all with asthma have access to asthma meds regardless of their presenting symptoms. Whatever is learned by the encounter of use for the family or community is not shared for improvement of the family or community.

 Who Is For Teleprofit
  • Innovation Bandwagon Promoters
  • Those who desire to profit from Telehealth
  • Primary care providers diverted to telehealth from undersupported primary care with more added to do each year
  • CEOs, recruiters, and managers organizing the telehealth
  • Researchers who want telehealth to look good and fund studies
  • Those who don't care what happens to local workforce
  • Drug companies (doing well by convenience care predicts doing well by telehealth)
  • Dermatologists
 Who Should Not Be for Teleprofit
  • Local primary care practices
  • Local leaders hoping to improve local economic impact
  • Those who understand that dollars diverted from local care can damage local workforce and local outcomes
  • Those seeking value in health care (outcomes / costs)
  • Primary care associations seeking to keep their members active in primary care positions rather than being diverted to numerous other ventures
A Question to Ask Local Community Advocates and Leaders Representing Rural Health, Primary Care, and Local Access

The question is,
  • Do you want local family practice bringing dollars in to your community into a practice or local health system where team members also work locally and spend dollars locally in ways that can help reverse the disparities that actually make outcomes worse
  • Or do you want to ship your scarce local dollars to someone sitting at home in a high concentration setting adding more to health care costs and sucking dollars out of communities that most need dollars - employed by CEOs making much greater sums.

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