Healthcare Dive has an interesting telehealth story about my former employer:
The University of Pittsburgh Medical Center Health Plan Monday launched AnywhereCare, a mobile app that provides 24/7 access to emergency telehealth services to patients across Pennsylvania…
app users can access emergency clinicians at about half the cost of a health plan copay, ranging from $10 to $49 per visit
Wahoo — this is going to save a lot of money through diversion of low need, high cost emergency room visits!
Right?
Well……. maybe. It’s complicated.
There are three major effects that need to be evaluated.
The first is the positive story. Some people will use this app to determine that their immediate need does not require an emergency room visit that they otherwise would have used. They are better off as they don’t have the stress nor the expense of the ER. The system spends less money as aggregate ER demand declines and everyone is happy.
The next two stories are a bit more complicated. There will be some cases where a person will use the app. The tele-health specialist will look at the situation and send the patient to the ER. Here telehealth acts as a mobile triage unit. When my son was having bad asthma attacks, the nurse phone line performed this role and sent us to the ER. The difference is the patient is using a more expensive resource and then using the ER appropriately instead of just going to the ER.
The third story is a price response story. How many people who otherwise would have just grinned and beared it will use the more convienent and fairly low cost telehealth application? The worried well will drive up costs. We’ve seen this in other diversion efforts.
The Rand Corporation looked at how people responded to the proliferation of urgent care clinics. They found that there was a net increase in healthcare spending driven by urgent care centers. There was some minimal diversion but far more demand was now being satisified by the cheaper and lower hassle urgent care centers. People who had complaints that previously would have been a watch and wait situation before going to the ER were now showing up at urgent care centers:
Examining people who visited retail clinics for low-severity illnesses such as urinary tract infections and sinusitis, researchers found that in most cases people would have stayed home and not sought medical care if the retail clinic had not been available….the new study found that some people did trim spending by visiting retail clinics instead of costlier physician offices. However, such savings were overshadowed by the increased spending on new medical care.
There may be value in telehealth other than cost savings. Not worrying is valuable even if re-assurance adds to total net spend. But these stories are more complicated than diversion efforts are automatic cost savers.
Baud
Is there a stat on how many urgent care or emergency room visits aren’t urgent or an emergency?
narya
It IS complicated–I used an urgent care twice in the past 8 months, once because a fever was spiking above 103 and most recently for a sore throat. I would normally NEVER go for a sore throat, but I was preparing to visit someone w/ a compromised immune system and wanted to get on top of it if it just happened to be strep (It wasn’t). I would normally probably not have gone in for either of those, so a net increase in usage, but in both cases I was the only person in the urgent care facility (run by a major hospital/doctor group) so I figure I made their day less boring and slightly less expensive. :-)
raven
We were trying to save us and BCBSGA money when my bride broker her wrist in Florida last November. We went to and Urgent Care and they had her go to a unit int he same building that turned out NOT to be part of the UC. They charged $2000 for the X-rays and BC wouldn’t pay. I hassled them for a long time and the X-ray people finally admitted their “coding” error and reduced it to $200. When the X-rays showed the fracture they sent her to an orthopod and they splinted and scheduled surgery to put a plate in. I guess it was fortunate that our BC rep called and said “don’t do t, we will not pay for the surgery performed out of network”. That was understandable but they still won’t pay for the ortho visit. So, urgent care, I guess.
Skeptigal
Very interesting! Just anecdotal, but I have a nurse line available through my health insurance, and it’s saved us several potential ER visits with my toddler. It gives us a medical professional to talk with who can tell us, OK, here’s what to look out for, here’s when you need to go to the ER, here’s how to treat that symptom at home, etc. It’s a great service. But there’s a cost to everything.
David Anderson
@Skeptigal: Yep, but nurses are cheap(er) to staff and the nurses’ line is free.
Wapiti
We were covered by Kaiser health care when we lived in California, and they sent us a 3/4″ thick first aid book. It’s basically a troubleshooting guide: if you have these symptoms it could be this. Every malady has guidance on whether you should deal with it at home, see the doctor, go to the ER, or call 9-11. Handy book – we still use it 10 years later.
Pogonip
@Wapiti: I like the idea of the first-aid guide. We have a generic one but it’s always “Well, it could be nothing but see your doctor to be sure.”. I actually get more use out of one originally used by the Green Berets; it has such exotica as how to remove someone’s appendix or splint a fractured thighbone, but also covers minor ailments.
Barbara
At the federal level it has long been understood that there will be no Medicare telehealth benefit until CBO scores it as revenue neutral and thus far it has always come up as being a net revenue loss precisely because of number 3. In addition, as someone who has used a triage service, defaulting to the ER is more usual than not. For one thing, they are run by hospitals that have a vested interest in pulling you in. Telehealth makes a lot of sense for areas that truly have limited MD access. It is especially useful to primary care physicians who use it to arrange access to specialists. But it’s not clear to me that it’s something that really improves the system or infrastructure in a generalized way. The problem is that with the exception of a few specialties, medicine is still a hands on enterprise, and when you report symptoms over the phone, the person on the line has no way to check your heart or lungs or your temperature to determine whether your shortness of breath is the result of an impending heart attack, pneumonia or the common cold.
ETA: Even the most minimally staffed minute clinic has an advantage over telehealth in that respect. Even having a nurse present to check vital signs could make the use of telehealth assisted exams much better.
sherparick
I dislike the whole premise of this story and what it says about the United States in 2017. Everything is about cost and something is not worth doing unless it “saves costs.” I kind of think it is a good thing that people who would have just stayed home and suffered puking and with a fever with a urinary track infection or coughing, feverish, and splitting headache with sinusitis can go some place convenient and get treated and that pain and suffering relieved. We have cost problems in American medical care, but most of those costs have to do with rent seeking and monopolistic pricing. Further, yes there is a huge generation of people is getting old, and one of the by-products is that they start getting sick with increasing rate of chronic illnesses. It should be a good thing to care and relieve suffering for all these people, regardless of the cost. Further, if you are 20 now, some day, if you are lucky, you will wake up and wonder where 50 years went and find yourself 70 with a bad back and arthritis in your fingers. If Jared Kushner, Donald Trump, Peter Thiel, Diane Hendricks, etc. have to pay a little more in taxes as result on their 10s of millions of dollars of annual income for providing good care, well tough beans.
OzarkHillbilly
@sherparick:
No no no…. It has to do with Americans not being forced to spend even more for less.
Barbara
@sherparick: This is a good point as far as it goes. My point above is that telehealth as currently configured isn’t much better than Dr. Google, which a lot of people are already relying on. It’s not clear to me that paying for a slightly upgraded version of an internet search is a sensible step forward.
DHD
Hmm. We may have the worst wait times for emergency rooms in the developed world up here in Québec. But we’ve had this service for years now. You dial 811 (note that’s 811, not 911) on your phone, you talk to an Info-Santé nurse who tells you “go to the emergency room”, and it costs you nothing.
Barbara
@DHD: Nurse triage lines exist in the U.S. too, funded by hospitals (or insurers, in my case) and people call them without paying. They are highly likely to send you to the ER. For my kids, I start with their pediatrician, who will typically provide me with advice on what to do first and to call back in one hour to reassess. It’s the inherent limitations of telehealth that make it not worth paying for, in my view.
Bumper
Have you ever had a UTI? They can be quite painful. Treatment isn’t difficult but every doctor I’m aware of requires a visit to write the prescription. Because they have to test. Because you couldn’t possibly know if you have one. Even though every female who has ever had a UTI is able to recognize the symptoms. So NO, a UTI requires an urgent care visit if you can’t get into your doctor right away.
David Anderson
@sherparick:
Please note the last lines:
Barbara
@Bumper: If you have a doctor who you can call you can often get a prescription over the phone until you can get in to see them. The only kind of prescription for oral meds that can’t be phoned in is one for a controlled substance. Whether they are willing to phone it in depends on how confident they and you are that what you are describing is a UTI.
Racer X
The UPMC folks are some of the top Telehealth practitioners in the world. The technology works, the tricky part has been paying for it.
Ruviana
@Bumper: My experience was that they want to prescribe the right antibiotic. The wrong one can just increase antibiotic resistance. This happened to me once.
workworkwork
@Wapiti: Kaiser’s pretty good with this sort of thing – looking for ways to deliver care more cheaply.
Example: I was used to getting a PSA blood test during my annual physical from my previous doctor. When I switched to Kaiser, I was told that the latest research showed this test does more harm than good so they don’t do it anymore.
Example 2: When I was tracking my blood sugar post-surgery, I worked with a clinical pharmacist via email and the occasional phone call rather than having to do office visits.
Mnemosyne
I’m also guessing that urgent care clinics are seeing a boom because they don’t require people to take time off work to see a doctor. You can show up at the clinic after work to have someone listen to that cough you’ve had for three weeks and not lose any pay or risk losing your job entirely.
Dr. Ronnie James, D.O.
My wife is an EM doc who does telemedicine/ urgent care on the side for [Gargantua Health System] in a Northeastern city. Some impressions:
1) Telemedicine via [Skype] is mostly a convenience / gimmick. Most of it is worried well, occasionally you’ll have a good use case like the person who’s lost their meds on vacation and just needs an Rx called in. My wife says the lack if ability to use the stethoscope/ palpate is really not that much of a hindrance for most cases.
2) Telemedicine isn’t getting a ton of calls currently. My wife gets 3-4 at most during a 12 hr shift (and she’s the only person covering telemedicine for Gargantua on these shifts). It’s not for a lack of advertising, either. I’m not sure patients are totally comfortable with this model yet.
3) Urgent care is taking off like wildfire. That selling point is convenience – you’re getting care quickly without an appt, and without the long-ass wait your (presumably non-life-threatening) complaint would get in the ED*. The ED also doesn’t have to worry about you taking up space that more acute patients could use. A nearby ED in a much poorer part of town has an entire hallway that’s just for these type of complaints, it’s basically the only urgent care in the region.
* Case in point: our 5 yo son has had a few minor playground injuries (scalp laceration requiring closure, bruised/ broken heel requiring X-ray to be taken and read) & we were in and out of urgent care in 30 minutes both times. On a weekend.
Dr. Ronnie James, D.O.
My wife’s an ED doc who does telemedicine/ urgent care on the side for [Gargantua Health System] in [largish Northeastern city].
1) Telemedicine [it’s all video/ Skype*] is 90% worried well.
2) Telemedicine volume is very low; they have one doc covering telemedicine for the entire [Gargantua] system, and they typically get 3-4 calls at most in a 12-hour shift. This is not for lack of advertising, either. I suspect all our local health systems have adopted it to make sure nobody got the jump on them.
3) Urgent care is taking off like wildfire here, meanwhile; and the main selling point is convenience, for both sides. You get to see a doctor much much faster than you would in the ED, and the ED doesn’t have you taking up their physical (and mental) space when they have more acute cases to deal with. To contrast, a nearby ED in a very poor part of town (which lacks an urgent care) long ago had to basically convert an entire hallway to a row of chairs to handle these types of cases, and it’s a major drain to have a PA / physician popping out to deal with all of them.
So: urgent care helps take pressure off the EDs, telemedicine may someday take pressure off the urgent cares, but it’s not there yet.
* (FWIW my wife says just seeing the patient is extremely helpful, and the lack of ability to use a stethoscope or palpate a patient isn’t a major hindrance).
pseudonymous in nc
Late to this, but it reminds me of how optometrists and dentists serve as lower-middle-class health triage in the US in a way that isn’t really the case elsewhere. People who can afford the fixed cost of an eye exam or dental checkup also get more detailed screenings than in countries where a GP visit is either free at the point of use or a low (as in under $20) copay. Not sure if the same applies to Minute Clinics.
Telehealth in “is this urgent/” situations feels more like a salve for the worried well (or as others have said, a wetware version of Dr Google); it’s more useful (up to a point) in bridging the urban/rural/remote gap for things like mental health treatment.