Telemedicine Tales

Yves here. A few months back, I described my Luddite biases about telemedicine. On the one hand, the idea of allowing established patients to consult with an MD outside an office visit is a big plus. Even before getting to Covid-19 concerns, it saves patient time and hopefully allows patients whose work or family demands makes it hard to free up time during normal office hours to get treated. On the other, the US being the world capital of rentierism, it isn’t hard to anticipate that telemedicine will often provide lower service levels with no corresponding price reductions.

Below, we feature a post by a clinician who confirms our concerns. He had advocated telemedicine in the pre-Covid era. He warns that telemedicine is creating cookie-cutter by design “doc in a box” practices, for instance restricting participating MDs in the tests they can run.

It had not occurred to me that the telemedicine services provided to MDs would be anything more than established MDs consulting with patients by phone, as they routinely did in Australia in the early 2000s, and/or getting a secure videoconference line. Earlier this year, in Alabama, my mother’s crusty MD reluctantly did her annual exam by phone. But my regular doctor in New York insisted on video (I needed an office visit for her to consider giving me a new scrip), claiming it was necessary to be “HIPPA compliant.” That made me wonder if she thought she was required to retain a recording. I didn’t find that acceptable (I also generally hate videoconferencing with the passion of a thousand suns) and flew to New York instead (yes, I am insanely protective of my medical privacy).1 This discussion of the tech of telemedicine makes me think I am less nuts than I did before.

This post doesn’t acknowledge another pet peeve: in Australia, telemedicine in the form of phone consults for established patients was well established. It was also understood to be a supplement to office visits, not a substitute for them, and priced accordingly.

Due to Covid-19, CMS mandated payment parity for telemedicine visits. This is unfortunate since for some, perhaps arguably many types of concerns, a telemedicine session simply cannot allow for as much diagnosis as a live visit. 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.

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.

By Cetona. Originally published at Health Care Renewal

1. Introduction. This post might just as easily be entitled “tales from the crypt,” so far down the netherworld chute have American public health and medical workers been plunged. Nowadays whenever I speak to fellow physicians and tell them I’ve moved on from my own front line patient care, we exchange these utterances: they say “congratulations, I’m envious” and I say “my condolences.” But the topic for today is more focal: telemedicine in the Age of Coronavirus.

Telemedicine, or “telemed,” doesn’t quite fit neatly into my ongoing series on why my dander’s up. So for now let’s set it aside and come back another time. It turns out that telemed—remote diagnosis and treatment using telecoms—is, like so many other innovations in health care, a two-edged sword. Let’s look at it and see if we can come up with provisional answers to what, exactly, it means, beyond fear of face-to-face, to see its use soaring these days.

I’ve observed telemedicine now in a number of settings—lots of testimonials from colleagues, family, friends, and in just one instance myself as patient. Most of this is quite recent, for reasons we’ll get to. I’ve never practiced it, never had time on my schedule to Zoom into some patient’s bedroom. That’s just an artifact of the timing. But I used to teach about it. And now it’s arrived like gangbusters after languishing for decades in the ever-hopeful hearts of long standing organizations (here, here) devoted in part or in full to digital medicine.

The “why” for this onrush of telemedicine exposure is an easy one. In the Before Times, we had reimbursement problems that impeded it. All the other barriers, by, say 2010, were secondary. All our clocks now have a thick black line between BC and AD. Before Coronavirus versus After Donald.

Back in the BC, we can’t get it paid for. Now, in the almost-AD: HHS rushes out new emergency regs, enabling telemed. With the pandemic, the new regs arrived just when providers, deprived of adequate PPE and in some cases a big chunk of salary, really needed the option. Whether they actually approved of it or not, different story. Necessity is the mother. All the rest is dross.

The above remarks set the stage. We just need to remind ourselves in passing: there’s just not much scientific evidence for this technology’s safety or efficacy. Rather, like so much else in digital medicine, telemed is probably here to stay because of one or another regulatory or epidemiologic crisis. Contrariwise, it’s not an evidence-based imperative, at least not with respect to clinical results. For providers, of course, it may well mean survival, a different story.

So until we get more convincing science, here, for this blog’s intrepid readers, are some narrative bits and bites to chew on: telemedicine, the good, the bad, and the ugly.

2. The Good. The single telemed session I undertook as a patient, reviewing some physiatric maneuvers, went rather well. So, too, did a family member’s. When teaching about telemedicine I used to fret to think about its lack of touch. A cardiologist recently related some of his difficulties he’d had—the need to evaluate heart and lung sounds, to feel the liver—and how he recently almost lost a patient by relying on telemed. In that case, the common dreaded complaint of “I’m so tired” proved to stem from complete heart block. But this cardiologist didn’t diagnosis his patient’s CHB by telemed. He did it when he had the good sense to send that patient to the ER.

Conversely, I watched a vertigo patient properly and fully worked up, including appropriate neurologic testing. Vertigo is so often of the benign positional variety that this all made sense, with discussion of all the diagnostic and therapeutic maneuvers, the extensive taking of a history that can nail some diagnoses, and discussion of follow-up. There are lots of instances where such outcomes are possible. Physical therapy is another area where a session may go quite well.

Then, still in the “good” column, there’s the public health benefit. An Associated Press release about telemedicine and coronavirus in Florida recently—this was late August—underscores the benefit. The AP release, available widely, e.g. here, didn’t seem to get a lot of traction beyond its own republication. Maybe it was just drowned out by late summer vacation blues, gladiatorial politics, and whatever other Daily Outrage we’re all lately subjected to.

In a relatively underserved area of Jacksonville, the site (or one site) of the GOP Convention days earlier, an aging public health nurse, like so many health workers faced with COVID-19, had a telemed session with a family physician, Dr. Cain. Both belonged to a minority community especially hard hit by the virus. Which is to say, hard hit by recent Florida politicians’ methodical dismembering of the state’s public health infrastructure. Privatization is one causative element of the systematic down-rating of public health in places like Florida. Ideology is undoubtedly another. Poor people’s bodies are a favorite target of budget-cutters. They really don’t matter, right? So those bodies get thrown under the bus. Always were.

Telemedicine can be a boon to the underserved, a patch on our deficits in social justice and public health. That was the case for Ms. Wilson, Dr. Cain’s patient, who received assistance and did well. In the right hands—largely, I’d say, telemedicine offered by academic health centers (AHCs), but also in community hands such as Dr. Cain’s—it can make a difference in narrowing the gap. Further, lest we view this as somehow second class, many patients in all socioeconomic categories prefer it—see the next section below—to going in and sitting around in waiting-rooms at either AHCs or community clinics.

3. The Bad. That’s true even in the best of times. But as we know, right now we’re not in those times.

On to the bad and the ugly. For the reader’s consideration I submit a recent report (personal communication) from a colleague—a highly educated and sophisticated tech CEO—who’d enrolled as a patient in one of those “with six you get egg roll” deals with a telemedicine start-up. Right now a great number of telemedicine providers are based on free-standing start-ups: I know this because on a daily basis I receive at least one entreaty from such companies to throw my own hat in their ring. (Which was damned tempting by the way.) I’ve lost count, and I wonder whether there’s any way to count up the entities that provide which kind of care. If there is, please add a comment below and tell me where that study’s to be found.

Meantime, let’s just put out there a typology—then let me how many of each you think there are.

  1. Academic centers’ operations, now rampant, and generally fairly good (or as good as Zoom), in the AD time of coronavirus
  2. Dr. Cain’s operation and other, similar, community-based ones (private/small group)
  3. Start-ups, which might or might not be conceived as extensions of physical docs-in-boxes

You tell me. Meantime, having talked to a lot of providers and patients who earn, or save, cash by participating in the doc-in-a-box style telemed shops, I’d like to tell my tech confrere’s tale. Actually, let me let him tell it in his own words, substituting StartUp for the particular telemed company name.

I was overdue for my yearly physical, and since I had a subscription to StartUp, I decided to use the telehealth service for my physical.  I didn’t have any major complaints, but I wanted to get some routine labs taken to make sure all was well.  I fired up the … app and after giving a brief description of my concern and a few minute wait, I was virtually face to face with a doctor.  I’ve been on Propecia in the past, and have recently started it again during the COVID lockdown.  I knew my family physician often ordered a PSA test while I was on Propecia, so I thought it would be prudent to ask for the lab to be included in my blood work.  Things didn’t go so well.

Me:  I’m on Propecia, and I know my family doctor often ordered a PSA test in the past, can we include that?

Doctor:  What’s Propecia? 

Me: It’s Finasteride.

Doctor: Is that something your doctor prescribed?

Me: Yes.

Doctor [emphasis added here and below]: Well, they don’t like us to order labs that require followup, so… 

Me: OK (I figured at this point it wasn’t worth arguing the finer details of [StartUp] policy and I was reasonably sure the PSA would have been normal)

Doctor: I’m ordering the labs, but sometimes they don’t go through, so if there’s a problem, just contact support and they’ll sort things out.  Also, don’t forget to follow up once you get the results.

OK, so other than not knowing what Propecia is, not being able to order the PSA test and the fact that none of the tests might actually have been ordered, the call went pretty well. 

I made an appointment with Quest Diagnostics through the … app for early the next morning to have the blood drawn.  After arriving at Quest and signing in, I was told there weren’t any lab tests that had been requested for me.  I was prepared for this, and showed the receptionist the StartUp lab order PDF.  She looked at it and quickly said that they couldn’t accept this as the order didn’t include the doctor’s name and she wouldn’t know where to send the results.  I left, went back to the car, launched StartUp and requested another virtual consult.  After explaining to the doctor what Quest told me, he said it was strange but that he would re-request the labs.

Armed with the new lab request, I went back to Quest, and spoke to the same receptionist.  She noted that it looked like someone “had done something” but there still weren’t any lab tests to be found.  She also noted that their systems “weren’t connected to anyone else”.  At this point, I pushed back as I was fairly certain the lab tests were lurking in the Quest system and it was possible that the receptionist just didn’t have experience or training with StartUp lab orders.  After some back and forth I was able to get her to enter the number provided with my lab order and was cleared to get the test.  As an added bonus, the Quest receptionist incorrectly told me that my insurance had been cancelled, only to later realize that she had entered my ID number incorrectly.-

This was on a Friday, so I expected I would receive results early the following week.  On Tuesday I received a notification that my labs were available in the Quest portal.  I checked out the labs and then opened the StartUp app to initiate a follow up call to review the results.  Only one problem, according to StartUp the labs were still pending.  I sent a message to StartUp support and they said that normally results are available in the app as soon as the lab has them and that they would work with engineering to figure out what had happened.  Twenty=four hours later, there’s still no word from engineering and the labs are still listed as pending in the app.

I am lucky enough to have a distinguished physician as a friend who was kind enough to look over the labs and give me the all clear.  Without this connection, I would have been left wondering about the results and given that the StartUp doctor didn’t seem familiar with Propecia (a common medication), I’m not sure I would have fully trusted their evaluation of the results.

It’s no wonder that people who go to doc-in-a-box (or NP-in-a-box) sites typically do so for only the simplest and most straightforward complaints. And it’s no wonder that the venture and hedge funds that capitalize these outfits do so in many cases while advertising they focus only on high-yield, low-risk diagnoses such as erectile dysfunction and contraception. Maybe the odd UTI or URI.

Oh, and colleagues who work for them tell me they exercise all sorts of mind-control, telling the providers what to say and what they can’t say. Sadly, docs do this stuff (in category 3 above), often to moonlight and they just swallow their gall. Easy enough on the ‘net to find out, however, exactly what they think about working for these outfits. But how many patients buy into it, as my colleague did, not knowing all this background?

In so many cases, therefore, it’s all just another golden exercise in American ingenuity and lapping the cream. In no way is it, in its free-standing version, a response to the challenge of improving health care. Rather, it’s the usual and sad response to improving investors’ wallet contents.

4. Footnote: the Price of Admission. You can’t do telemedicine without a good connection. But many who might most advantageously avail themselves of telemed consultation don’t have that adequate connection. For those who’d like to read more about this conundrum, Brookings has just published a Techtank blog, by Visiting Fellow Tom Wheeler. He offers useful solutions in a piece entitled “broadband in red and blue,” with some concrete and hopeful ways of redressing what’s essentially yet another AD (After Drumpf) problem: the way the US has been closing the Digital Divide more assiduously for red than for blue states. The challenge, per Wheeler: “[t]here are almost three times as many Americans without a broadband subscription in blue urban areas than in red state rural areas.”

People currently thinking about back-to-school issues, and kids’ telelearning, probably aren’t thinking quite as much about telemedicine, despite the striking parallel. But they should Beforethey get sick.

The problems of telemedicine mirror those of the larger society, as does health equity mirroring societal equity. This will come as a surprise, no doubt, to precisely no one. Let’s hope after November we get to putting the solutions, and the promises of telemedicine, into more socially just practice.

_____

1 Not about to bore you with details, but my records and notes stay with my MDs. My setup is very atypical for the US and I intend to keep it that way.

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24 comments

  1. jackiebass

    It seems to me that a doctor can’t effectively and safely diagnose and treat a patient without personally seeing them. There are many serious diseases a doctor often finds by actually seeing the patient. This is just another way for our corporatized medical system to make more profits. It will result in poorer quality of care. Medicine is like education. The experts don’t have the final say. Insurance companies hinder doctors in treating patients. In education the experts, teachers, have little or no say in education policy. Until this changes both systems will not provide the quality they should.

    Reply
    1. Carolinian

      It’s an Alice in Wonderland absurdity. If all the physician is doing is giving you advice you can do that for yourself via the internet. And it sounds like you may even get better and more accurate information. Says it all that the only reason they hadn’t gone this way already–according to the article–was due to difficulty getting paid. That’s our true US medical system concern in a nutshell.

      Reply
      1. RPG

        This hits on a big part of the war on science which is both devaluing humans self worth and the value of experience. The same logic that makes people treat their bodies less well than their cars is what allows society to treat 100s of thousands of covid deaths as ‘it is what it is.’ As a physician I am astonished how willing people are to trust the care of their most precious asset, their body, to reading a few internet articles (provided and paid for by some of the most manipulative technology ever created)

        I always see someone else for my family and my own care as I have learned that a doctor’s experience trump’s knowledge almost every time, but even more importantly, that there are significant cognitive biases and blind spots involved in self diagnosis.

        A lot of people won’t touch their car, furnace, or electrical system but are so happy to self diagnose their body and mind despite all the self-referential pitfalls.

        I see too many sadly advanced cancers and other diseases people are 100% convinced was something else after going down some internet wormhole. They deny the truth until the end.

        Everyday I am overwhelmed and humbled at the complexity of the human body and disease. Yet also everyday it seems I am lectured by some facebook expert so self assure of such obviously erroneous information. In a professional setting I obviously do my best to educate but as in private life , confrontation in this era is rarely fruitful.

        I know it’s trendy now to demean medicine and doctors as greedy crooks, but some of this is just a purposeful narrative being fed in order to facilitate crapification of health care via replacement of doctors with PE owned midlevels and computer controlled algorithms.

        Sadly, the future will make us long for the present.

        Reply
        1. sharonsj

          Unfortunately, the internet is the only source of easily accessible knowledge for people looking for specific medical information. My doctors wanted me to undergo both chemo and radiation, which I refused until I could research the effectiveness for my particular problem. I discovered that this information was not available from touted cancer organizations. It was available from medical journals and medical websites for doctors but (1) the journals wanted money either annually or per journal article and (2) the medical websites wanted even more money. I couldn’t afford either so I ended up reading many hundreds of abstracts instead and then made the best choice I could. I don’t self-diagnose but I do self-medicate, but that’s another story.

          Reply
        2. Carolinian

          Did you read the article? It complains about the telemedicine doctor not even being familiar with the author’s disease. Indeed the whole notion of diagnosing and prescribing via video goes against everything you just said. Why are they doing this? Because the noble healers don’t want to risk being exposed.

          And of course there are plenty of doctors who are altruistic, appropriately knowledgeable, risk what they have to risk, not in it for the money. Unfortunately it’s by no means all of them. Having nursed an aged parent in her latter stages through the medical system I speak from experience.

          Reply
          1. RPG

            I did, and empathize with both you and the author. Corporate telemedicine is another crapification scam as is corporate medicine in general. They pay low rates, skim fees, and require grueling work to obtain anything close to a regular physician salary. The only way it will survive long term is using NPs/PAs. They wont attract the best providers obviously so its quite expected quality will be bad. Its almost by design. The goal is quarterly profits or selling to the next PE group. Health care is beside the point.

            In terms of covid however, I take issue with your assertion that ‘noble healers’ dont want to be exposed. You realize we are in a pandemic right? Hospitals, clinics and providers are likely to be agents of disease spread. It would be unethical and immoral to operate a crowded clinic for routine health care. Could you imagine especially a geriatric, obesity, or diabetes clinic? These patients are at terrible risk already. Grouping them together in crowded situations with sick patients would not go well. Look at nursing homes for an example..

            One of the few simple joys left in healthcare is interacting with patients, most would rather this be over and get back to normal. Despite the outrage propaganda, this is not some huge profit boon for most. Most people I know have taken significant loss in income and work because of covid.

            There will always be bad actors, especially now during covid they will try to ram telemedicine down our throat claiming its necessary. The majority of these are not health care providers. Noone I know desires being a doc-in-a-box. Its a degrading amazon factory type dead-end .

            Good people working hard and acting ethically will never induce enough outrage to make it on anyones news feed. It doesnt mean there arent lots of them in every field across the world.

            Reply
            1. jrs

              Anyone blaming doctors for telemedicine doesn’t know what they are talking about. Elderly patients especially are afraid to go to the doctor. It’s telemedicine or nothing.

              Reply
              1. Yves Smith Post author

                You make clear you didn’t read the post. That’s a violation of site Policies. You are accumulating troll points.

                The post describes that there are start up, telemedicine-only practices that are paying big bucks to recruit MDs and by design providing crappy service. This has NOTHING to do with the elderly not wanting to see their current MD in person.

                Doctors selling out for profit IS an MD problem.

                Reply
        3. Arizona Slim

          Wishing for a medical profession that was more like you, doctor. Unfortunately, you are the exception, rather than the rule.

          Reply
        4. Janie

          My 90 year old relative is a great diagnostician. He practiced medicine in the lightly-populated midwest. Without the new-fangled tools, he had to rely on observation. People still call for advice, even tho he’s been retired for years.

          Reply
  2. The Rev Kev

    I can see where this is going to go. At first, it will be qualified doctors and specialists that people will be consulting via telemedicine. Then over time, you will have registered nurses being used for simple calls like rewriting scripts and the like. Given more time, it will be nurses and medical students that will deal with most people on telemedicine but that will have “special” training to do so. In the end it will be the same people that work for health insurance companies judging people’s applications that will be doing all the work – and using the same priorities.

    Reply
    1. Keith

      My medical plan had already used nurses for that well before COVID. I found them useful, to. They can advised if you really need to go to the doctor or stay home and rest. A nice benefit when you are sick, otherwise you get sucked in the hassle of trying to get an appointment, then traveling back and forth. Adding doctors to the mix was the new thing.

      Reply
    2. Oh

      You forgot Physicians’ Assistants who play the role of the Doctor even in the Doctor’s Office. Two years of training and they know it all! The insurance folks love ’em.

      Reply
      1. furies

        Yeah, that disturbed me when I was working as an RN.

        (or, it was *one* of the things that disturbed me)

        When your nursing job goes against your ‘right livelihood’ vow~

        Reply
    3. freedomny

      Where I am in upstate NY you can’t even get a primary care physician – the waits are like 6 months. And medicine has gotten to the point that providers are more than happy to set you up with another pill to take instead of helping you to get to the root of the problem to begin with. Patients and physicians are both guilty of this – a family member who is a doc was more than happy to take a statin so he could continue to eat McDonalds….

      Reply
      1. Keith

        In my experience, doctors being nothing more than a glorified drug dealer goes back at least a decade. Part of the reason I stopped using them in the first place.

        Reply
  3. Keith

    I had my own experiences with tele-medicine. The first time it was great, as I was feeling ill. I was able to talk to a doctor within ten minutes without leaving my home, a big plus when you are sick. She was able to provide a doctor’s note and send me for a COVID test. Plus, it was free under my insurance.

    Second time, it was worse. I had been admitted to the ER for GI issues and had to stay a couple of days. I was discharged and told to see a doc within a week of discharge. Well, I was able to get an appointment two weeks later, as I do not have a primary care as I go to the doctor when sick. The day of the appointment, the assistant called to tell me that I could not come to the office, but had to do a video call with the doc, for the same price. Then, maybe I could get an in person visit. This was because the meds prescribed to me mimic two symptoms of COVID, and they were a “clean” facility. Best part, if I didn’t cancel four hours prior, they would also charge me full price. So I ended up firing them. Luckily, I was able to find an office that was accepting new patients (another pain) and that would see me personally.

    In the end, this seems more like a more strealined method to increase billable hours while decreasing workload.

    Reply
  4. Cuibono

    There is a world of difference imo between seeing a patient via telehealth who you already have a well established relationship built in person and a patient who you dont know well. The former has been delightful for me as an MD and even more so for many of my patients. The latter can be unsatisfactory and even unsafe.

    But that said I can easily see where this is all heading…crapification. If you like phone support for your PC from Delhi you are going to love telehealth from there

    Reply
  5. juno mas

    So why not have doctors/nurse-physicians travel to the patients in special vehicles (like the dog groomers)? They could put advertising on the outside and likely gain new patients.

    The vehicles could be outfitted with needed medical appliances and space for client observation/diagnoses. During the pandemic a pop-up tent could be set up in the open air outside the vehicle for safety sake. What’s not to like?

    Reply
    1. ambrit

      One, not a large enough net profit for the “investors.”
      Two, the “medicos” would still be potentially exposed to germs from the patients.
      Three, think “pandemics,” plural.
      (A separate tent is not needed. One of the roll out awnings used on RVs would do the trick. The basic medical supplies could be housed in lockboxes that open outward and be mounted in the sidewall of the vehicle. Indeed, take the old lunch truck design and build a sliding window access to the inside in the vehicle’s side covered by the awning.)
      Finally, do consider the Social Darwinian aspects of the present situation. There are those who would not shed a tear at the premature ‘passing’ of large swaths of the ‘deplorable’ population. Denying adequate healthcare to some can be seen as a policy choice.

      Reply
    2. Keith

      Hopefully, a result of this new “on demand” culture could be home visits by medical staff. Pricing would need to be adjusted, but I suspect many would be happy to pay a little more for this style of care.

      A bonus factor, it could reduce overhead for the doctor. He would need have as much of a need for an office and could possible pool office space with others, driving down costs if the practice home visits. Testing can be farmed out to labs and hospitals, like they oftentimes already do.

      Reply
  6. Yik Wong

    Me: I’m on Propecia, and I know my family doctor often ordered a PSA test in the past, can we include that?

    Doctor: What’s Propecia?

    Me: It’s Finasteride.

    Doctor: Is that something your doctor prescribed?

    I’m wondering if the telemarketing* doctor really is a licensed MD (in any state in the USA) and not a nurse or nurse practitioner, possible overseas**, mostly reading from a script. It’s inconceivable that one of the most widely advertised (next to erection medication), prescribed medicines in general practice is unknown to a licensed MD.

    *intentional misuse
    **I’m being optimistic here. Perhaps there is a country where doctors have men begging to be naturally bald.

    Reply

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