Why I’m Not Keen About Telemedicine, US Style

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During coronavirus, getting access to medical advice without the contagion risk of getting to and sitting in an MD’s office ought to be a big boon. So what’s the beef?

Perhaps I was spoiled by the sensible implementation I saw in Australia nearly 20 years ago, when the insurance-hamstrung approaches in the US don’t measure up. I was paying non-insured rates, which were still cheaper than in the US, which in Sydney were A$75 for a first visit to a GP, ~A$150 to A$200 for a specialist (dentists, which were not covered by the Australian insurance schemes, were more pricey). Everyone seemed to have an electronic records system that was more straightforward and doctor-friendly than US versions. But more important for this discussion, after the initial exam, doctors didn’t need to have office visits to get paid. My recollection was that it was A$25 for a phone consult and A$15 to get a new prescription issued. And I don’t recall there being a charge for an MD-initiated follow up.

This mode of operating fit well with the prevailing treatment bias, which was not to do much unless it looked to be warranted. The Australian MDs I met and heard about are not big on heroism. Their default seemed to be to suggest to wait and monitor the symptoms and see if they got worse. That made them markedly less fast to prescribe than American doctors.

It frustrated me, when I got back to the US, that I couldn’t call most doctors between exams and say, “I’m having these symptoms. Do you think I need to come in?” The one exception was my orthopedist around the corner. I was pretty sure I had broken my little toe by stubbing it badly. I called him the first thing in the morning to get on his schedule, telling his assistant why I wanted an appointment sooner rather than later. He called back on his first break and said, “I don’t want you coming in over something like this. Tape your little toe to the next toe.”

Before getting to various anecdotes, one reason to have reservations about it is that it is inherently inferior to an in-office visit, as was explicit in the pricing in Australia. The doctor cannot listen to your lungs and heart, stick a light in your ear, see your skin color accurately, poke your belly if it needs poking, or examine body parts that are not behaving normally. And if the doctor provides a treatment, it would seem probable that at least for some patients, the placebo effect would be reduced.

Now since the telemedicine is cheaper for the MD (less appointment time due to less examination, no need to use a treatment room), it should be priced lower. But that isn’t necessarily the case. From MobiHealthNews:

Another reason telemedicine might not save money is because of the increasing popularity of telemedicine parity laws, which require that payers reimburse for a telemedicine visit at the same rate as an in-person visit. [Dr. Ateev] Mehrotra [an associate professor of health care policy and medicine at Harvard Medical School] said those laws are a big mistake from a savings perspective.

“Telemedicine parity laws, at least the form that say ‘Hey you should reimburse this telemedicine visit at the same rate as an in-person visit,’ make it very difficult for telemedicine to save money,” he said. “When people talk about teledermatology, for example, they say an in-person dermatology visit costs $180 and a teledermatology visit costs $90, that’s a 50 percent savings. And that’s true, that will accumulate, but if you have telemedicine parity laws you make it impossible to save money in that manner.”

Ten states provided for “true parity” and California had just joined that list. Coronavirus appears to have greatly boosted that practice, no doubt to preserve doctor incomes. From mHealthIntelligence on April 1:

CMS is adding more than 80 new telehealth services to the list of services covered by Medicare during the Coronavirus pandemic – and reiterating that all connected health services are now reimbursed at the same rate as in-person services.

Tuesday’s announcement from the Centers for Medicare & Medicaid Services is a strong stand by CMS, as payment parity has long been considered a linchpin to nationwide telehealth adoption. Several states have passed emergency declarations recently that mandate payment parity in Medicaid programs and for private payers, the latter of which have long argued that they should be able to negotiate their own reimbursement rates with providers.

“Providers can bill for telehealth visits at the same rate as in-person visits,” the order states. “Telehealth visits include emergency department visits, initial nursing facility and discharge visits, home visits, and therapy services, which must be provided by a clinician that is allowed to provide telehealth. New as well as established patients now may stay at home and have a telehealth visit with their provider.”

But this is unlikely to be treated as a coronavirus emergency measure and phased out if we ever return to anything like the old normal.

However, with coronavirus, I find doctors to be pushing telemedicine, which unlike my experience in Oz, means a video conference. And a lot of it seems to be a bad second best that will produce poor outcomes. For instance, I had wanted to see a physiatrist (aka physical management and rehabilitation) specialist in NYC in January, but his office was impossibly difficult.1 Now that coronavirus has apparently slammed his practice, they have been calling me regularly about setting up an “initial consult” for telemedicine. Huh? The doctor can’t do anything important without examining me live, like test my joint mobility, look at my alignment and my gait, and poke around for inflammation. Similarly, an trainer/physical therapist has been pushing me to set up a video session. Again, I can’t fathom how that works, since he can’t observe me well, particularly if I were to attempt any new exercises. He can’t see my form in three dimensions.

My regular MD offered to do telemedicine for a more routine matter, but with my aversion to photos and videos of me out in the wild (save for the necessity of promoting the site), I didn’t understand why the video part was necessary. The informational part could all be handled on the phone. Her assistant said it had to be videoed to be HIPAA compliant. That seems odd to me. My mother’s doctor is similarly pushing for her to do a video appointment, with one of us to download an app to smartphones neither of us have. The acute care service through which we hire private-duty nurses says Medicare does not require video and allows for phone appointments with MDs, so I wonder where my regular doctor got her concerns. Perhaps it is a New York State issue, or a restriction imposed by some of her insurers.

On a much bigger picture level, it is troubling but typical to see telemedicine implemented now reactively, and not proactively. Why don’t hospitals have hot lines for overnight triage for those who don’t have MDs or the subset of MDs that don’t have after hours emergency lines? Finding a way to charge, say $50 or $100 for a quick reading (which could be credited to an ER bill if the patient was told to come in) could help reduce use and costs. And another theoretical advantage is to use telemedicine in rural areas where doctors are scarce. Yet instead of pushing deployment there, it’s heaviest use pre-coronacrisis in urban areas.

In other words, a practice that ought to be a boon looks set to become a vehicle for crapification. And the US medical system is pretty crappy to begin with.

_____

1 No joke, it took two months, including multiple calls with my insurer who also volunteered to read the MD’s contract with them, to get past the MD’s billing office view that it was “illegal” for the doctor to have me pay his charges in full, personally, at the time of service. When I called Cigna the first time about it, the rep and her supervisor were, not surprisingly, utterly gobsmacked that any MD would think that. I came away wondering if the office was engaged in billing fraud.

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43 comments

  1. George

    My first experience with telemedicine occurred a few weeks ago, when doctor offices were closed and hospitals restricted to emergency and urgent care matters only. It went swimmingly well. As a result of the clinical assessment (albeit relying solely on Q&A), I was booked for an urgent procedure and biopsies at the local hospital. The outcome: the worst case (cancer) was ruled out and medicinal therapy was commenced immediately. I wouldn’t hesitate to use telemedicine again when appropriate.

  2. jackiebass

    My doctor left for greener pastures. The health care group suggested a Telavisit. I almost laughed at them when they said it was to get acquainted with my new doctor. My gut feeling is that in my state of NY where doctors visits have been reduced that this is an attempt to make money. If I’m going to get acquainted with a new doctor I want to meet them in person. I respectfully declined and said I will wait until June and see if conditions are then safer to visit the doctor.

    1. grayslady

      My doctor left for greener pastures. The health care group suggested a Telavisit.

      Exactly the same thing here. I don’t have a problem with a video conference, but they were suggesting a telephone visit or a video conference. I explained that I would never begin a relationship with a new doctor by telephone. I was then told that I had to have Microsoft Teams installed in order to do a video conference. There are numerous problems with setting up Teams if you already have a Microsoft account (anyone who has registered their Windows system has a MS account), especially if you don’t have more than one email account; and the medical organization refuses to allow the doctor to set up a Guest account–which would clearly be the easiest method rather than insisting that every patient install the bloatware that is Teams. Fortunately, my pulmonologist is also board certified in internal medicine, and he’s agreed to cover my needs for now should they stray outside of pulmonary. I realize the importance of medical privacy, but, honestly, why must they make it so difficult to teleconference? I’ll just stick with the system’s internal email for now, I guess.

  3. juneau

    All valid points. The payment restrictions on telemedicine have held it back in the US. Prior to the crisis, insurance reimbursement was only allowed when patients lived in an underserved area and was determined by zip code per CMS regulations. Registration and paperwork was required and it was basically discouraged. And payment for phone time and refills were not allowed through insurance. I agree video meetings are stressful, can be embarrassing and limit privacy since patients usually have to do it from home.

    I hear the plan is to reduce fees for remote visits-the parity now is temporary to limit the number of office closures. The online scheduling portals need to be updated and email often substitutes for calls. It is transition that will require money to update websites and will likely lead to much less income for practices and individual doctors. Since current overhead is fixed that would likely mean cutting overhead, i.e. more furloughs, salary cuts and layoffs. It is really up to CMS to decide whether they will allow it. Many docs don’t charge for refills or phone calls but may start if they lower visit fees for insurance patients. The triage of appointments is key and should be done by clinical staff not schedulers.

  4. lyman alpha blob

    Telemedicine parity laws? So they’re blatantly legalizing the grift now?

    I really don’t see how this is all that different than calling the doctor’s office with a minor ailment and asking them if you should come in. And that is free, although generally you are talking to a nurse or an assistant in that case, and not a doctor.

    1. joey

      You answered your own question at the end. Also of note, medicare had a rule in place that it is illegal to charge for a phone consultation, no matter how involved, unless there is a presigned release because it wasn’t medicare eligible. Telehealth parity was to ensure telehealth visits (clearly superior to phone calls because inspection is one of the four means of examination) weren’t lumped in the other way with telephone.

      Cheaper or not isn’t the question, is it truly equivalent? For most visits no, it is inferior, but it is superior to a phone call. For that reason telehealth parity was to incentivize practitioners to provide telehealth to underserved areas whose populants would otherwise have to drive hours each way for an office visit. If the cost and efficacy of telehealth were both inferior, why would any practitioner offer it during the past normalcy?

      The fact that most of the visits this past month have been urban is actually ideal for its purpose of allowing for care (and some of the business end) to continue without spreading the virus. The only reason most doctors will continue to do it is to have a middle ground of service that isn’t a cause of contagion. It is certainly a less thorough examination.

      1. Yves Smith Post author

        I do not see how a video conference is superior to a phone call. No additional information is conveyed except in a minority of cases, and then not well (looking at swelling over a video screen is a very poor proxy for examining it live). In fact, I would argue it’s worse because the accuracy of any visual exam is so illusory as to be misleading.

        1. Ahinsa

          The video is not essential for the communication and should not be relied on to make a diagnosis not unless one has high resolution systems as used by radiologists. However for established patients it brings a sense of belonging to the visit which is very reassuring and helps reinforce a message. On the other hand issues with connectivity can frustrate these efforts and intentions.

        2. Joey

          Seeing swelling is better than hearing it described by the afflicted. Non-verbal communication is mostly caught by a ‘talking head’ camera shot.

          No offense, but to argue otherwise sounds like a radio man dismissing TV. ‘Illusory’ compared to less information?

          1. Yves Smith Post author

            You really must not get examined. Do you pay any attention at all to what your MD does even during a routine visit?

            You can’t see a swelling in two dimensions. You can’t see colors accurately. And if you really think an image helps, an e-mail of a photo or two would do at least as well. I know people who refused to have a dermatologist telemedicine visit for precisely this reason, who thought it was ridiculous to examine a skin ailment by video.

  5. Mark

    As an Australian I do enjoy your throwback comparisons to your time in OZ… From my personal perspective I do think that you have had a particularly good experience here. I haven’t perceived that telemedicine is particularly accessible here and a brief google doesn’t suggest my experience is an outlier…

    Regardless, I mostly have no complaints about our health system. I shattered my ankle last year. I had surgery within 9 hrs of admission from a leading surgeon in the state. All covered by the system including rehab.

    As far as systemic failure goes, US health does seem to lead the world here. From top to bottom the system seems full of perverse and distorted incentives. Total market failure in what is supposedly a market system.
    (That said my one personal experience of medical care in the US was quite good and reasonably priced.)

    Anyway, I’m rambling. I love the US for many reasons and look forward to my next visit. Though I fear the world will be scarred from 2020 and the USA more so than many places.

  6. timotheus

    An anecdote about telemedicine with a tragic ending.

    Ese Olumhense, “Family of Bronx woman who died in childbirth gets $2K hospital bill,” The City, May 5, 2020 https://bit.ly/35FXOFd

  7. rd

    Re: doctor not accepting payment up front

    My experience with family/internal medicine practicies is that they are largely overwhelmed by the complexity of the billing and insurance systems they are dealing with. They have been working hard over the past decade or so to get these systems up and running so they can at least function. Once they have a protocol that works, they don’t want to change anything because it could be a whole new learning curve.

    Complexity is a feature, not a bug, to the upper couple of percent. To everybody else it is just a bug. The complexity allows for lobbyists to work on government, it creates the requirement for intermediaries to do anything at all (a hallmark of corruption in many countries), and it creates lots of revenue opportunities based on the sheer number of bullshit jobs created. The biggest single job loss in a single payer health care system would be the insurance/billing system workers. Right off the bat, probably 25% of the costs in US healthcare could be eliminated without changing any frontline medicine practices. This is why there is such an intense focus on maintaining the status quo and creating complex new systems like Obamacare.

    1. Oh

      Obamacare created more complexity but provided a windfall for the insurance grifters by providing them public funds. By allowing the same rates for telemedicine as for office visits CMMS is again shoveling $$$ to the healthcare industry. The insurance boys will increase rates using this as an excuse.

    2. fwe'zy

      The billing footnote: not defending them, but it did remind me of car accident insurance. Possibly the MD billing office was thinking of the car accident insurance warning to avoid onsite cash settlement offers by the other side, and stick with insurance to work it all out.

      Innocent enough but of course it shows the adversarial nature of today’s corporatized MD visit, and the incentives for intermediaries to benefit from the private insurance infrastructure. I’m not against bureaucracy or professional expertise, or layers of actors in an ecosystem, if it’s not distorted by a core agenda of profit extraction and astronomical looting by insiders/ the top.

      My wonderful gyno, who was also my mother’s gyno, retired early and told me that if she’d wanted to be a businesswoman, she wouldn’t have gone to medical school. She was a beloved, extremely popular doctor and professor, as well as an honorary African tribal chief.

    3. Yves Smith Post author

      Not “payment up front” but credit card or check payment at the time of service, as in when I left the office. I pay and I submit to my insurer for reimbursement.

      The big reason I do it this way is I am not in any network (I have an old-fasioned indemnity plan) and this way, the insurer does not have access to MD records except in the cases of a big deal billing dispute, and then only what additional information the MD submits. All they get normally is a diagnosis code and a procedure code. Even though I am very healthy aside from my joint issues, I still don’t like the idea of insurers having all sorts of data about me that they don’t need to have.

      The second reason is for any tests (like imaging or bloodwork), the “cash” rate is typically cheaper than, or at least no worse than, the best insurer negotiated rate. The total opposite of ERs, where “cash” clients are screwed to the max.

  8. Brooklin Bridge

    In terms of corruption, or corruptive tendencies, we are practically in free fall. There is absolutely nothing, not even a global pandemic and a looming epic depression that isn’t ruthlessly exploited to extract more for less even as capitalism collapses upon itself and it’s captive poor.

    One still sees compassion and empathy, as well as remarkable energy and brilliant intelligence, but it is fast becoming simply overwhelmed, bent and redirected every time and anywhere it pops up and tries to get a foot hold, most of all in the US and our satellite failures.

    Hospitals and states can’t even order protective gear without the federal government stealing it out from under. It’s mentally very difficult to appreciate just how truly insane and evil that is. As to virtual doctor’s visits, it will be one more rivet popped that encourages ethical and caring doctors to retire early or get out while they can.

    And the Cornavirus isn’t what caused this, it is this that caused the Corona virus.

  9. Teledoc

    As a Doctor just starting telehealth during COVID times I agree overall with your comments. A few quibbles though. I still have the same overhead with telehealth visits. The history, meds, insurance info, records,etc all have to be created. It takes about 30 min staff time to do the prep work with a new patient, plus walk them thru the app at least once. Eventually overhead cost will drop, but for now the rent and salaries and FTE are all unchanged. Did you not consider this?
    The state restrictions, liability, hipaa, and quality of care concerns precluded my interest in telehealth, but now my hand is free and CMS has temporarily waived telehealth HIPAA requirements. Telehealth for older patients has been very helpful. I too thought such visits would be worthless, but unneeded office vists have been avoided, patients reassured, and pandemic risk reduced. Older patients especially seem to enjoy the visit.
    The precision and accuracy of diagnosis are reduced, but patients are triaged faster and at a lower overall burden in terms of travel, COVID risk, and time cost. This is a tremendous advantage. Yes?
    Okay, I agree some visits will be duplicative, but they will be billed lower as they are return vists. In my patients, we will know exactly why and what is to be done prior to arrival and this will reduce in office contact time and COVID risk and increase efficiency of resource use.
    Your docs are calling you because their practices are dying on the vine and this is the only care they can safely provide. Yes medical costs are driven by greed, lobbyists, special interests, oh the list is endless. But somewhere in there is the need for care.
    Telephone visits are allowed and now paid equal to office visits, but a phone call is a limited bandwidth visit.
    Finally, telehealth is here to stay. It is a communication channel with its own benefits and limitations, just like IRL, text, email, phone, and Facetime. Eventually I will be able to reduce rent overhead. Telehealth payment will reflect this. For now, I just want to keep staff and patients healthy. Reduce COVID risk. Maybe even stay solvent.

  10. jbp

    I’m a doctor although as a surgeon I find Telemedicine less useful (I do use it for some postop visits if the patient is doing well and they can send me a picture of their incisions).

    I think where it will prove most useful is for managing chronic conditions like hypertension or diabetes in remote areas (no local doctors) or for patients who don’t want to come in to the office (a lot of primary care for chronic conditions could be done over Telemedicine since the physical exam is low yield for things like blood pressure checks).

    Unfortunately, the video aspect is a rule with certain insurances ie Medicare (the doctor won’t get paid if there isn’t a video component to the visit). This requirement is being waived in many areas due to COVID19.

    All these issues are largely artifacts of our current fee for service system.

    As far as the doctor pushing for Telehealth: Volumes are way down in healthcare. I’m sure your doctors are worried about their practices / loss of income. Everyone is pushing us to do more Telehealth to generate some revenue. I worry about permanent destruction of healthcare capacity as the pandemic drags on.

    The jobs report this morning showed 2 million jobs lost in healthcare. My income is down 80% and will not fully recover any time soon (maybe never). The hospital I work at has laid off hundreds of nurses, housekeepers, etc and we are expecting that everyone who still has a job will be forced to take pay cuts if this drags on beyond the next few months. I know that the nursing school here in town has seen all its upcoming grads have their job offers withdrawn. Healthcare is one of the worst areas to work in right now (since outside COVID19 hotspots, volumes have crashed and even in hotspots the hospitals are losing enormous amounts of money and don’t need dermatologists, orthopedic surgeons, ophthalmologists, etc).

    I was set to move home and take a new job but all the physician job postings have been pulled indefinitely (I had 2 interviews scheduled in early April that were both cancelled and the job postings taken down). Not sure what I will do now. In the worst case scenario, I may have to change careers to get closer to family. It is much harder living 1000 miles from family with travel being such an issue during the pandemic.

  11. Felix_47

    The only reasonable solution I can see after many years of practice in both medical areas and surgery is to nationalize health care and put all doctors on salary. Have them work fixed hours. We already do this with firemen/paramedics. The most important part of care is the first few minutes when they arrive at the site of the calamity. They are on salary. They are paid very well. They do a good job. Why should the payment system change when you hit the ER? Putting doctors on salary would eliminate the incentive for unnecessary treatment or surgery. Doctors would have to make decisions based on what was best for the patient. Half of all surgeries are thought to be uneeded. The money saved would be astronomical. If the government is going to ocnsider health care a human right there is no place for private practice. And if the government is going to pay for it, which it is, the taxpayer should have the ability to control it to include overuse, malpractice, and other abuses. And if it is a government system the lawyers can sue the government.

  12. John Jones

    The title of this little piece says it all especially “not keen ” and “US style”.

    I cannot comment on the “US Style” as I’ve never had cause to use the US health care system despite 20 years of visiting the great US country. Perhaps I just “lucked in” by not having any ( known) health issues on my numerous visits.

    My beef about the post is the phrase “not keen” – rarely in health related matters is “not keen” a used term. Health and the effects of bad health ought and more probably , need to be addressed.

    In the UK even Before Corona ( BC) we have a creaking NHS which is buffetted by an increasing number of users /stakeholders – and that’s just the indigenous population never mind the health tourists from around the world who use, abuse and effectively undermine the overall ability of the NHS to provide high quality care to its valid user base.

    I learned long ago that the appetite for healthcare was infinite yet , as per all countries, the capacity to treat everyone at all times is just not going to happen.

    Thus to telemedicine – sure it has downsides and its many detractors – equally, when one ( you) are ill , I really don’t care if I’m seen in person or, in the limit, at the end of a screen – to get diagnosed quickly and despatched to the appropriate secondary care system ( say hospital ) for the requisite treatment.

    Sure, in an ideal world it would be great to have the individual face to face consultation with a GP – unfortunately we don’t now or ever have lived in an ideal world ( it ain’t that kind of movie ….as they say in Kingsman) – me , I’ll take , no, will be keen to use telemedicine any time if it’s the only pragmatic option available – especially so if it were my little toe🤗

    1. ChiGal in Carolina

      the point, I think, of the post was that there is a danger that telemedicine will be exploited/generalized to situations where it is NOT the only pragmatic or even a wholly inadequate option.

    2. Yves Smith Post author

      Sorry, you really do not get it. “Not keen” because:

      1. Some of my beefs are personal prejudice, like in general not liking being photographed or videoed. I am going to much greater lengths than most people to protect my privacy. I am really annoyed at the insistence that these sessions need to be videoed, as opposed to on the phone.

      2. Some of my beefs are due to my particular health issues which are overwhelmingly orthopedic and hence extremely ill suited to telemedicine.

      The objective part of the beef is that telemedicine is inferior to a regular office visit save for the convenience factor for the MD and patient. There is inherent and inevitable information loss. As in Oz, it should therefore be priced lower.

      I can see the argument that while coronavirus is on, it should be priced the same due to lack of alternatives, but the idea that the price should be the same on an ongoing basis (save for a specified subset of cases where a telemedicine visit really is as good as an office visit, like monitoring chronic conditions) is all wrong.

      1. Joe Well

        I have had telehealth video-consults where I couldn’t get the webcam working in the first minute or so and each time the doctor just said, “well, let’s just go ahead without video.” Another time he actually called me on my phone. Just a thought if you absolutely can’t get out of the video-consult…

        Also, I’ve regularly communicated with my primary care physician via his HIPAA-compliant web portal contact form (at no extra charge), and I once asked follow-up questions to a specialist via text messages and emails, at his encouragement. As for doctors not wanting to take phone calls, in my own work I strongly prefer not getting calls as well, just for practical reasons.

  13. anon in so cal

    “Why don’t hospitals have hot lines for overnight triage for those who don’t have MDs or the subset of MDs that don’t have after hours emergency lines?”

    Some provide a 24/7 hotline with registered nurses who can assess and recommend.

    1. anon in so cal

      To follow up, there is:

      “Talk to a Doctor Anytime, Anywhere
      Cough, sniffle, fever, rash or emotional issue. It’s not an emergency, but you’re feeling lousy and would really like to talk to a doctor about your symptoms. But it’s 2 a.m. No problem. Board-certified LiveHealth Online doctors and psychiatrists can diagnose, recommend and prescribe medication for many common non-emergency medical and behavioral health issues. Doctors are available 24/7 all year long. There’s no waiting in a crowded emergency room or urgent care center.

      Why Use LiveHealth Online?

      LiveHealth Online can help:

      After normal office hours.
      When your primary care physician or pediatrician isn’t available.
      When you are considering the ER or urgent care for non-emergency medical issues.
      When you have limited access to emergency or urgent care because you are in a rural area.”

  14. vegeholic

    i called my doctor in the middle of march to propose a phone visit rather than a face-to-face visit to discuss an ongoing issue and to get a prescription refill. he said that they “were not set up to do phone consultations”. so i had to go and sit in a waiting room with other strangers in the middle of a pandemic for something which was entirely routine. i suspect this was entirely due to their not having a way to get full parity reimbursement from the insurance company for phone visits. i suspect they know how to use a telephone. i’m pretty sure this policy has been changed, but the rules are all made by nitwits and grifters whose only concern is the billing.

    1. Katiebird

      About that time, I told my doctors nurse that I would have to stop taking some medication because I couldn’t go to their office with the pandemic lockdown. She immediately agreed and said the doctor would extend my prescriptions. I THINK I’ll have to make an appearance in June. But that may depend on the situation here at that time.

  15. ChiGal in Carolina

    As a psychotherapist, I never had any interest in teletherapy, thinking it likely ineffective and unethical (online confidentiality, an oxymoron).

    Being now forced into it, I have been pleasantly surprised. The platform I use is doxy, which requires no downloading or installing on anyone’s device, and creates a VPN between patient and therapist. It is HIPAA compliant (unlike Zoom) and remarkably stable (much better than Skype for example) and there is an in-the-room intimacy that enables depth I wouldn’t have thought possible virtually.

    Of course my clients, unlike the vulnerable populations I worked with in the past, mostly have home offices they are able to commandeer for their appts so they have the luxury of privacy.
    Another way Covid Time! heightens the great divide that sickens the body politic. I do have one client who works in theater which is shut down so to survive got a job as a shopper at a big box store. IMHO grocery stores etc. are total vectors—the behind-the-scenes view ain’t pretty.*

    Being in a small private practice that continues to pay rent though we are all working from home and to pay salaries for two support staff (still waiting for our PPP to come through—hah!), I am grateful that insurance companies have enabled these services at parity. Some of them have also waived all cost sharing as well (a total crapshoot).

    *they should be handing N95s out like candy and putting people to work manufacturing them on a massive scale. those people are completely vulnerable and then they go home and infect their families.

    1. fnx

      As someone who has for years resisted getting a webcam for my desktop computer, I can attest that using doxy on a smart phone is not ideal. Have resorted to Duo video calls with my therapist, I had to physically see my pain doctor after a failed attempt at using doxy on my end. While I would consider getting a webcam at this point, they are all sold out due to the rise of people working from home.

  16. Democrita

    The problem isn’t that telemedicine — or online education or whatever you want to transfer online — is by definition bad. The problem is that it is not being designed to any purpose other than extracting value for capital.

    Not too long ago I had a couple of investment managers tell me how great telemedicine and online universities would be, if they could only get those pesky doctors and teachers out of the way.

    1. joey

      Licensure remains key mainly to protect telehealth from becoming a means of offshoring. Don’t let the universities catch on to the benefits of offshoring teachers, tenure is fading and there aren’t as many protections.

  17. juno mas

    Great discussion by the commentariat! My local hospital/clinic has introduced tele-medicine. The sessions are currently free (yes, free). It seems they’re trying to acquire experience with it before instituting pricing.

    Let me give some advice for computer access to tele-health: invest in a quality web cam and lighting capability. Also buy a good USB microphone. The better the doc can see and hear you the better the session will proceed. Soon enough the pulse-oximeters will morph into B-Pressure/Infra red temp/oximeters that can be directly connected to your laptop. The vital signs taken by nurses before you normally see the doctor.

    (Be aware that stand-alone webcams and quality mics are currently selling at a treble price premium. If you can wait till June prices should fall back.)

  18. Laura in So Cal

    I think like most tools, it can be useful if used correctly. Years ago (2007?), I used to do phone consults with my son’s specialist who didn’t take insurance. I would submit and get partial reimbursement because it was a phone consult. The specialist was 400 miles away so after our initial appointment, we did everything by phone. She would input lab orders to our local Quest, she would get the results, and we would consult about Once every 3-6 months or so. It worked great.
    Recently, Kaiser Geriatrics did their 6 months “visit” with my Mother (who has an Alzheimer’s diagnosis). This was a phone consult with my Mom and my Dad just to assess and check in with them. This was mid-March and my parents cancelled because they didn’t want to go to the Medical Center because of the Pandemic. Kaiser called them and said they could to the phone consult. Normally, I would drive them to the major Kaiser facility an hour away to do this.

    I think this would be great to do with a Doctor I already had for follow-up or routine work. I don’t think I would be comfortable doing this with a new doctor.

  19. Sue CA Desert

    I’m a retired insurance lawyer now disabled with chronic illness. I personally have no problems with telemedicine, however I do have issues with Zoom and Skype, which are not encrypted. The idea of the creation of a VPN connection between patient and physician by the therapist is excellent. I think due to the outrageous mishandling of this virus, we’re likely going to be reliant on telemedicine and will be medically unprepared for live appointments for the long haul. Asking for a secure connection if telemedicine is to be required is not unreasonable by any means, in my opinion. I agree that we desperately need universal health care, but that won’t happen for a long time as I see it as long as health organization CEOs are calling the shots. They will fire doctors and nurses before they give up that profit.

  20. Ahinsa

    Medicare started by paying $12 a visit for a phone call regardless of time in the COVID crisis before going with a little higher rate of reimbursement, and then finally achieving near parity with a face-to-face visit. Video visits were appproved at parity with a regular visit and will be so for a time limited duration.
    After having done this for the last 2 months, I can assure you these visits are not only inefficient but likely to be error prone for the vast number of Medicare beneficiaries
    The problems include 1.) technocompetence 2.) broadband connectivity and 3.) availability of smart phone and tablets and laptops. 4.) sensory (hearing and visual) and cognitive deficits.
    Flyover country lacks the resources to meet points 1.) to 3.)
    Audio or audiovisual visits take extra time esp. with the elderly. Documentation time is not concurrent but follows the “visit” and one often has to include written instructions to make sure they were fully understood
    These visits are best suited for single issue problems like colds, diabetes medication adjustment etc.
    Regardless of reimbursement, elderly patients or patients with multiple medical problems are best served in the office setting

  21. Cuibono

    I called him the first thing in the morning to get on his schedule, telling his assistant why I wanted an appointment sooner rather than later. He called back on his first break and said, “I don’t want you coming in over something like this. Tape your little toe to the next toe.”be able to see patient

    Your ortho doc is a smart businessman. You see, he knows that the only reason he sees patients in the office is to be able to see patients in the OR. No way your toe would need an OR trip. So why waste time.
    Literally , they schedule just enough people to fill their OR schedules

    Now this may not be your ortho doc. For all I know he is a saint. But this is the business model. Toes need not apply

    1. Yves Smith Post author

      This is not at all correct. I found this doctor from a friend who had seen Lord only knows how many MDs because she had back pain, they wanted to operate, and she didn’t want to have surgery.

      She finally got to him. He said, “You don’t need to have an operation, but you need to do exactly what I say.” That was to stay in bed for six months.

      It turned out well for her. Not only did she not need the surgery, she did a monster commercial real estate deal, netting her $3 million in fees (this in the 1980s, so even more in current $ terms) from bed in her nightgown. She had lawyers visiting her in her bedroom.

  22. Norseman

    Telehealth & videohealth need a lot more thought. Excellent points raised above, but as well, before doctors conclude it is great, hear the other side please and don’t over-congratulate just yet.
    From my experience listening in to a consult my wife had with an old-style grumpy authoritarian dominating male endocrinologist, who was just palatable & functional in an office consult, but showed his lack of personal insight into himself, the patient’s needs & the limitations of the communication medium (in this case telephone) so much so that the consult was a disaster for the patient and ended in tears. He lost a patient that day, as did the doctor who referred her to him.
    The medium allowed him to instantly take charge, dish out incorrect diagnoses, criticise the patient for not complying (he misheard) and over-rule her attempt to correct him & ask questions because he made clear he was tired at the end of a long day & Telehealth didn’t pay enough to give time to patients. So some doctors need training in how to use it effectively and when.
    One Swedish Telehealth company has software that allows the doctor to almost always look at the patient, provided they can touch type notes and multi-task. It shows the patient at size on the screen centre, but allows the doctor to bring up overlays, around the sides of the screen, showing patient history, test results etc as needed so that the doctor always appears attentive to the patient, can see the body language reactions to the doctor’s comments, and can do some note taking in the consult rather than later, which means higher accuracy in notes.
    Just like radio, tv and movies all need different approaches by scriptwriters, actors, directors etc., doctors need to get the best out of the mediums they use with some hard thinking, training and feedback before they pick hardware & software, or pick up a mouse or a phone to consult with real people.

  23. PlutoniumKun

    I’ve heard two sides of this recently, one from a friend who is an emergency department physician, and a relative who is a family doctor. Both have found it unsatisfactory for the exact same reasons – its resulting in cautious doctors sending far too many patients to emergency rooms because they can’t eliminate simple explanations for symptoms the patients (especially elderly patients) are finding it hard to articulate over a phone/skype link.

    The family doctors in particular are fretting over the conundrum of whether its better to have potentially ill elderly people stay cocooned at home or whether they should have tests for potential issues in the hospital. This calculation is changing daily as the hazard perceptions change.

  24. dagan68

    I am a primary care provider in the Intermountain West – dozens and dozens of miles between each tiny town. We have been doing telemedicine since the pandemic started –
    I mostly have bad things to say about it. Frequent freezing and pixelating. Just a very minimal amount of external physical exam findings are available. The 1-2 second delay in transmission is very offesetting to normal conversation. Elderly folks just simply do not get it – and cannot even remotely set things up on their own. For some reason, I feel absolutely exhausted at the end of the day – and this has never happened to me before – I do not understand the reason why.

    All that being said – it is good for 3 situations – when the patients are very geographically far away – it can handle about 75% of issues. When the patients are elderly and hard to move for the family – it can be a lifesaver – and for quick limited visits – ie test results – it is ideal.

    Otherwise – this just is not going to cut it.

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