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Why I’m Not Keen About Telemedicine, US Style

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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 to be 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.

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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 incredulous that any MD would think that. I came away wondering if the office was engaged in billing fraud.

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