Telemedicine: super convenient, but hidden drawbacks need attention

During the pandemic, millions of us — locked down, fearing infection, and in need of medical care — got a first dose of what some advocates say is an overdue health-care innovation: telemedicine.

The federal government gave a huge boost to virtual treatment on an emergency basis by allowing its use in novel ways and expanding payment for it.

But will the nationwide experiment with telehealth endure, or will it fade like the run on hand sanitizer and crates of toilet paper? There’s much at stake for patients and doctors, including the accessibility, cost, safety, and quality of medical care, as policy makers consider the future of telemedicine. So, zoom in here and see why …
 

Could the consumer experience be any worse for so many patients visiting emergency rooms, doctors’ offices, clinics, or hospitals?

There, they endure huge inconvenience. Appointments aren’t always easy to get. Patients need to take time off and maybe travel across town on crowded streets or jammed public transportation. They can struggle to find parking and pay a premium for it. They sit for uncomfortable periods in waiting rooms jammed with sick, injured, and upset people. When doctors see them, the visits are brief — an average of 16 minutes. And that time may be eaten into by providers taking electronic notes and administering recommended screenings (say, for depression, substance abuse, and tobacco use).

Virtual care could address many of these concerns, advocates say.

It can offer much greater convenience, increasing access to care with patients “seeing” their doctors from their homes or even their workplaces. For those with disabilities, serious mobility issues, or transportation challenges, this could be significant.

The optimists’ scenarios

Telemedicine also could extend medical services to those in exurban or rural areas. It might give patients access to specialists (cardiologists, neurologists, and cancer experts) who otherwise might not be available in their communities.

The federal Centers for Disease Control and Prevention says doctors could provide coaching and support for patients managing chronic conditions, including weight management and nutrition counseling. Telemedicine could allow patients to participate in physical therapy, occupational therapy, and other treatments in hybrid fashion, with both in-person and online sessions.

It could be used for doctors to monitor patients’ clinical signs of long-term disease (e.g., blood pressure, blood sugar, other remote assessments). It could be a good way for doctors and nurses to follow up with patients after hospitalization, or to discuss advance care planning and end-of-life concerns with them. It might be a useful way to increase non-emergency medical oversight in nursing homes and other long-term care facilities.

The Trump Administration, which pressed a Republican agenda of deregulation amid its chaotic pandemic response, embraced telemedicine, getting federal regulators to allow its greater use and covering many costs for it.

Optimists envision scenarios in which patients, ahead of time, fill out paperwork and undergo tests at home or in a medical lab. Then nurses or physician assistants might start a virtual medical appointment, assisting patients — using video conferencing in the comfort and privacy of home — in getting key measurements (temperature, blood pressure, weight, and height) and addressing their current care. These well-credentialed health workers could conduct appropriate screenings and start discussions about patients’ prescriptions and current care. Doctors then could jump on, as appropriate, for diagnosis and treatment. This process could run more efficiently and pleasantly than many office visits, advocates say.

A push for virtual mental health care

Enthusiasm for virtual mental health care spiked during the pandemic, and this area of medical services may be particularly ripe for high use of telemedicine, experts say. It is helpful in eliminating the stigma of mental health and substance-abuse treatment, bolstering patients’ confidentiality and helping to break down their isolation. While virtual counseling has become trendy enough that it is a component of a series on cable television’s HBO ( “In Treatment — see photo above), remote mental health visits are increasing due to a shortage of available services and heightened demand. Specialist groups in this field have issued best-practice guidelines, including discussions on dealing with patients in crisis.

As the nonprofit, independent Commonwealth Fund reported last June:

“[T]ere is increasing evidence of a mounting surge in mental and behavioral health care needs because of the pandemic. While formal data are not yet available, anecdotal evidence shows an increased demand for mental health services that is overtaxing the mental health care system … Because minorities and people with lower incomes are being disproportionately affected by pandemic-related job losses and social stress, we also could see heightened heath inequities. Telehealth can rapidly expand access to safe, effective treatment in a way that has also been shown to avoid stigma.”

Elisabeth Rosenthal — a onetime practicing physician, a former New York Times health reporter, and now head of a health news service and a commentator on health issues — has written about telemedicine’s surge:

“By April 2020, one national study found, telemedicine visits already accounted for 13% of all medical claims compared with 0.15% a year earlier. And Covid hadn’t seriously hit much of the country yet. By May, for example, Johns Hopkins’s neurology department was conducting 95% of patient visits virtually. There had been just 10 such visits weekly the year before … the financial world is abuzz with investment opportunities. In the first six months of 2020, telehealth companies raised record amounts of funding, with five start-ups each raising more than $100 million. There are now telehealth apps that target niche markets like the mental health of pregnant women. Others provide medicines, like HIV prevention pills, after a virtual consultation with their doctors. You can even do a digital eye appointment, meet with your dentist virtually to monitor your oral health and orthodontic progress, and send a dermatologist a photo of a suspicious mole.”

Who, by the way, can ignore that the most publicized popular telehealth offerings include online consultation for erectile dysfunction and male hair-loss treatment?

Before modern medicine stampedes into telehealth, critics say, the approach needs much more study and proof that it improves patient care.

Here is some of what Dr. Rosenthal wrote in a recent New York Times Op-Ed:

“Covid-19 let virtual medicine out of the bottle. Now it’s time to tame it. If we don’t, there is a danger that it will stealthily become a mainstay of our medical care. Deploying it too widely or too quickly risks poorer care, inequities, and even more outrageous charges in a system already infamous for big bills. The pandemic has demonstrated that virtual medicine is great for many simple visits.

“But many of the new types of telemedicine being promoted by start-ups more clearly benefit providers’ and investors’ pockets, rather than yielding more convenient, high-quality, and cost-effective medicine for patients. ‘Right now there’s a lot of focus on shiny objects — ideas that sound cool — rather than solving problems,’ said Dr. Peter Pronovost, a national expert in medical innovation at University Hospitals Cleveland Medical Center, who has written about finding the value of virtual medicine. ‘We know preciously little about its impact on quality.’”

Skeptics have reason to question virtual care on multiple fronts, including:  A concrete understanding of what it is and what patients, insurers, and the government are expected to pay for it. Whether it really increases access to care or if it may worsen already serious economic and racial disparities in medicine. If it provides excellent outcomes for patients in its various uses. Telemedicine is not totally new, but basic concerns like these arise because, until the pandemic times, it had not had such wide use.

What we know already may give pause

The information emerging from recent experimental use may give many reasons for pause.

Despite the hype for virtual care, much of it wasn’t delivered with the latest technology (online video conference sessions), but rather by old-fashioned telephone calls. As researchers from the independent, nonpartisan RAND Corporation found in looking at treatment offered between March and August 2020 in select California health centers, “Among primary care medical visits, 48.5% occurred via telephone, 3.4% occurred via video, and 48.1% were in person. For behavioral health, 63.3% occurred via telephone, 13.9% occurred via video and 22.8% were in person.”

The patients who phoned rather than using video services were predominantly poor and people of color. They turned to calls rather than visits partly because of the pandemic, but also because this care now was covered due to coronavirus-related changes in federal policy, the researchers found. The skew of poor patients may have been affected because the study focused on services provided by public health centers.

But another RAND study, based on pandemic-era care for millions of participants in an employer health plan, reported in findings published in a medical journal that:

“There was a substantial increase in telemedicine utilization during the Covid-19 pandemic. The increase disproportionately benefited higher-income, metropolitan-dwelling adults. Other studies have reported that before the pandemic, communities with poor geographic access to health care disproportionately utilized telemedicine … There was also evidence that low-income communities have exhibited lower uptake of telemedicine. Possible mediators for the differences in the subgroups could be cultural/political factors and differences in educational levels.”

While video conferencing may sound like a cool way to deliver more health care, experts underscore that concerns already run high about the economic, geographic, and racial differences in online services across the country. The Biden Administration has proposed spending $100 million to address the “digital divide,” because, as the tech-focused news site CNET reported:

“Biden [has] talked about the fact that more than 30 million Americans, including 35% of rural Americans, live in areas without any access to broadband. And in urban and suburban markets where broadband is available, it’s often too expensive. This reality hits minority families harder than white families, creating digital inequities. The coronavirus pandemic, which led to shutdowns across the country, made the issues even more apparent, especially for students who struggled to connect to the internet for distance learning.”

Doubts on diagnoses at distance

Patients, insurers, lawmakers, and regulators may be less eager to dive into telemedicine, despite its conveniences, if clinicians fail to ensure the safety and quality of treatment offered with the new technology, experts say. Here’s Dr. Rosenthal again:

“[T]here are things that virtual medicine can miss, studies suggest. One study showed that commercial telemedicine services were much more likely to prescribe antibiotics for children’s respiratory infections as a primary care doctor at an in-person visit. That’s in part because if you can’t see into the ear to observe a bulging drum, for example, the safer course is to overtreat — even though that’s contrary to prescribing guidelines intended to prevent antibiotic resistance.

“An internist depresses the tongue and looks for pus on the tonsils to detect possible strep throat. A surgeon suspects appendicitis by pushing on the belly to see if there’s pain with rapid release. Can psychiatrists develop a therapeutic relationship with a new patient equally well over Zoom? In some cases, sure. But better diagnosing of my own post-injury gait problems required office visits with hands-on maneuvers, like checking my reflexes and feeling my joints move. ‘There is still real value in being in the same room, in touch, in the laying on of hands,’ Dr. Pronovost said. Studies show that such interactions build trust, increasing the likelihood that patients will comply with treatment.”

Few of us — as so many of us discovered during the pandemic — have studio-quality setups in our homes. Even if we connect with video conferencing apps and software, the sound and picture can go awry. The systems are supposed to cyber secure, but reports flourished during the pandemic of crude “Zoom bombers” popping up invited into consumers’ sessions. And who also has not seen colleagues or students lose focus after long hours of participating in an online video session? This is not promising for the already fraught challenges of remote medical diagnosis and treatment.

Doctors already struggle with misdiagnoses. Safety advocates provide these scary data points from before the pandemic and put out by the specialists group, the Society to Improve Diagnosis in Medicine:

“Every nine minutes, someone in a U.S. hospital dies due to a medical diagnosis that was wrong or delayed. Roughly one in 10 patients with a serious disease is initially misdiagnosed  Diagnostic errors affect an estimated 12 million Americans each year and likely cause more harm to patients than all other medical errors combined  Misdiagnoses boost health costs through unnecessary tests, malpractice claims, and costs of treating patients who were sicker than diagnosed or didn’t have the diagnosed condition. Experts recently noted in a health care report that inaccurate diagnoses waste upwards of $100 billion annually in the U.S.”

Questions about over-use and abuse

More study is needed, but telehealth critics like Dr. Rosenthal raise concerns that this approach will increase wasteful over-use of medical resources. As she explained:

“With telemedicine generously reimbursed [in recent times], many [medical] practices are offering — even encouraging — patients to visit virtually. But, intentionally or not, that choice becomes a revenue multiplier, adding to patient expense. When he noticed a curious rash, a relative was first directed to a practice’s telemedicine portal and billed $235 for a five-minute video appointment. Since rashes are often hard to evaluate in two-dimensions, he was told he needed to see a doctor in person for the diagnosis and then was charged $460 more for that visit. I worry that pandemic-era reimbursement practices have taken traditionally free screening calls and rebranded them as billed visits, with no value added.”

Clearly, experts need to sort out telemedicine basics, including whether it is desirable, yes, to provide services to the poor, elderly, and far-flung with phone calls — and whether doctors should get reimbursed for this as if patients visited in person.

It also may helpful to policymakers and patients to consider that, historically, telephone calls have been a nightmare for doctors and their practices. In pre-pandemic times, doctors struggled to install enough lines and complex systems so they and their staff could manage the huge volume of patient calls — for appointments, prescriptions, referrals, and questions about care, and more. While many of us, indeed, have urgent issues we’d like to chat with health staff about, it seems that many patients — anxious without cause or confused or disorganized — also can take up a lot of medical practices’ resources with little to show for it. This is another concern for expansive telemedicine.

Federal prosecutors say patients and the public also have another cause for concern about telemedicine — its easy exploitation by bad actors. Law enforcement officials have busted up a pandemic-related scheme they say involved $143 million in fraudulent billings, including what they said were the “first in the nation charges for allegedly exploiting [expanded telemdicine reimbursement] policies by [doctors and others] submitting false and fraudulent claims to Medicare for sham telemedicine encounters that did not occur. As part of these cases, medical professionals are alleged to have offered and paid bribes in exchange for the medical professionals’ referral of medically unnecessary testing.”

Charges have been filed against “14 defendants, including 11 newly-charged defendants and three who were charged in superseding indictments, in seven federal districts across the United States,” Justice Department officials say.

.As patients watch the national discussion on telehealth heat up, especially concerning federal and insurer coverage, they should remember this basic truth:

It’s not about the technology, it’s about patients and their care.

Virtual treatments, advocates say, will be an important part of refocusing medicine away from big, shiny, and expensive buildings — towers of doctors’ offices or sprawling bling-bling hospitals. Patients say they want to stay in their homes as much as possible when ill or injured, not in distant, sterile, clinical facilities.

At the same time, however, we’re all waging an uphill battle against big forces in health care that the pandemic only made more powerful: Our graying nation for some time now has failed to deal with a looming shortfall of tens of thousands of needed doctors. This situation may worsen as stressed-out and burned-out health workers flee their professions after the horrors of the long pandemic.  Big, wealthy hospitals in recent times have only become more so. They were buoyed by federal pandemic aid, allowing them to sustain their finances and then to buy up competitors and doctor groups, reducing patients’ choices and potentially leading to increased prices for medical services.  Most doctors now work in ever-larger practices that increasingly are owned by hospitals, chains, or investors such as hedge funds, the American Medical Association reported. The pandemic slammed many smaller practices, forcing them into the arms of bigger and wealthier competitors.

These larger trend lines have created a damaging culture in medicine, argues Dr. Robert Pearl, now a professor at the Stanford medical school and former CEO of The Permanente Medical Group (1999-2017), the nation’s largest medical group. In a recent interview, he offered these painful insights into doctor-patient relationships and an “uncaring” medical culture that can turn lethal for both parties:

“I start with the view of [physician] culture that the patients’ convenience is not valued. That you should be grateful that I force you to come to my office and miss a day of work and get through traffic and try to park your car to have 10 minutes with me because I am so valuable. We have online tools to book a flight or a hotel, but you have to wait till the next day to call the doctor’s office to make an appointment. At five o’clock, we shut our offices down. They’re closed on Saturday and Sunday in general…There’s no continuity of care on the weekends. We could do it differently, but in the medical culture, we don’t see it as a priority. We see the physician’s time as a priority.”

Patients must push back, working with their doctors so their care stays where it belongs — as the primary concern, whether in person or remote. Pearl says patients should talk fearlessly with their doctors about fundamentals such as:  How much will this drug or treatment cost?  Is this procedure or treatment necessary? Who will lead or coordinate my care?  Can we talk about end-of-life matters?

Yes, and he stresses in a published excerpt from his new book that the discussions about telehealth may really be a way to air basic concerns about communication and how your doctor will help you:

“It took a global pandemic to help doctors and patients realize the benefits of virtual care. Not only did telemedicine keep doctors and patients safer during a viral outbreak (by keeping them apart), the experience helped everyone realize how many problems could be resolved through this widely available and convenient form of technology. Whether doctors continue to offer telehealth solutions in the future will depend partly on whether patients demand these services.

“Related questions for the patient: Can I make future appointments online rather than by phone? Is there any way to get some of my care through video rather than in person? Can I email or text you with any questions I have? How can I check the results of my laboratory tests online? How do I access my own medical record online? Doctors can give their patients relief from worry and stress by offering reliable and private access to online scheduling, video visits, secure e-mailing, and relevant medical information. Patients can acquire these time-saving conveniences, but only by demanding them.”

The suits who run big hospitals or massive medical groups may push doctors to be more efficient, see more patients, and spend less time with them, including by shunting a chunk of the care to terse online or telephone consultations.

Patients can walk away from that kind of factory medicine, avoiding big and bigger and seeking out thoughtful, compassionate, and excellent doctors committed to helping them.

It’s hard work to find good doctors, and especially those important primary care MDs. (It’s a major concern for older patients, as the federal government has realized, posting extensive online resources about finding and dealing with your doctor — click here to see this material.) But the investment in a productive search to do so can be crucial — it may save your life. At the very least, it could ensure that when you feel it is a must, you will see your doctor IRL (in real life) and not as a ghostly presence on the phone or a screen.

Of course, here’s hoping that you and yours stay healthy throughout 2021 and beyond and have little or need to deal with medical services, in person or remotely!