Can seeing a virtual doctor be as good as the real thing?
Questions emerge about telemedicine's benefits
By Shelby Livingston, Business Insurance, 8/2/15
In need of a way to provide efficient, affordable health care to its employees scattered nationwide, Pitney Bowes Inc. found a solution in telemedicine.
The e-commerce, shipping and mailing company's telemedicine portal, launched with American Well Corp. in April 2014, allows workers to visit the Boston-based provider's physicians — as well as Pitney Bowes' on-site clinicians, dietitian, pharmacist and oncology nurse for employees with cancer — through a real-time videoconference, said Mary Bradley, Shelton, Connecticut-based Pitney Bowes' director of health care strategy.
It helps boost employee productivity and saves money for participants in Pitney Bowes' consumer-directed health plan, Ms. Bradley said.
Employees “literally could have a virtual visit from their office,” allowing them to start recovering sooner than “if they had to wait for a physical visit,” she said.
Like Pitney Bowes, more U.S. companies are looking to telemedicine to expand health care access and reduce employees' out-of-pocket costs.
Last year, 22% of employers offered telemedicine services to employees, and 37% said they expected to offer telemedicine this year, according to a Towers Watson & Co. survey of employers with 1,000 or more workers. Another 34% were considering offering telemedicine in 2016 or 2017, Towers Watson said.
And IHS Technology, a unit of IHS Inc., has projected that 7 million patients worldwide will use telehealth services in 2018, up from 350,000 in 2013.
“There's a lot of interest and a lot of questions about what does (telemedicine) really mean to our future health care, how do employers embrace this, or should they?” said Linh Tacker, Tampa, Florida-based vice president at Aon Hewitt, who said she receives calls every week from interested employers.
Employers tap telemedicine hoping it will reduce costly emergency room visits for noncritical cases, increase health care access and reduce absenteeism, she said.
Telemedicine visits, which typically cost around $40, are cheaper than doctor's office visits, so they help employees in consumer-directed health plans reduce the cost burden, said Alexander Domaszewicz, Irvine, California-based principal at Mercer L.L.C.
Telemedicine falls in line with the strategy of urgent care, giving employees another option to save money. But some health professionals and researchers question whether telemedicine measures up to in-person care.
Telemedicine takes many forms, but employers who offer telemedicine often provide a direct-to-consumer model, where patients discuss their problem with a clinician through a secure videoconference.
This direct-to-consumer model is “where you get the controversy,” said Dr. Lawrence Wechsler, Pittsburgh-based vice president of telemedicine and chairman of neurology at the University of Pittsburgh Medical Center. “This system has to be applied where it can be applied effectively.”
In most cases, direct-to-consumer providers such as Teladoc Inc., American Well and Doctor on Demand Inc., limit treatment to conditions such as a runny nose, sore throat or simple rashes, Dr. Wechsler said.
The doctor should “be attuned” to that fact and “recognize when something is beyond what should be taken care of” via telemedicine, he said.
Another issue is the potential to overprescribe medications, particularly antibiotics, though he said his experience finds telemedicine prescribing rates on par with face-to-face rates.
A May Rand Corp. study agrees. It found that patients treated for acute respiratory infections via telemedicine video sessions were as likely to be prescribed antibiotics as patients who went to the doctor's office.
However, the study, which compared 1,700 Teladoc appointments with 64,000 in-person visits, found that 86% of telemedicine doctors prescribed broad-spectrum antibiotics vs. 56% for in-person visits, which Rand said increases costs and contributes to antibiotic resistance.
Teladoc did not respond to requests for comment.
“There's concern by organized medicine that the (direct-to-consumer telemedicine) care may not be as good, and I myself have become aware of several cases where care was less than optimal,” said Dr. Karen S. Rheuban, Charlottesville, Virginia-based medical director of the office of telemedicine at the University of Virginia Health System. “Self-reported symptoms aren't always the best methodology.”
Some experts say seeing a doctor you don't know could result in inefficient care. In a June statement published in the journal Pediatrics, the American Academy of Pediatrics said telemedicine should take place “within the context of the medical home.”
“Medical care delivered by the doc who knows the patient and the team of folks working with the doc will be better than care given by someone who does not know the patient,” Dr. Bryan Burke, professor of neonatology at the University of Arkansas for Medical Sciences and member of the academy's section on telehealth, said in an email.
He also said treating certain conditions, such as a red throat or painful urination, with antibiotics without in-person tests are practices “no reputable authority would condone.”
But Dr. Pat Basu, Chicago-based chief medical officer at Doctor on Demand, said in-person tests are not always needed, and the company provides equal or better care.
“The exact same thing that we would do in our offices we would do over video to make this diagnosis,” Dr. Basu said. Diagnoses are made following standards and evidence-based guidelines, or patients are referred for an in-person visit, he said.
“About 95% of our consultations end in what we consider to be full resolution of your diagnosis,” he said.
Other experts question whether a patient-physician relationship can be established without an in-person meeting, and some wonder whether telemedicine will be overused, reducing its cost-savings potential.
Many experts agree more research is needed to evaluate direct-to-consumer care as it relates to in-person care.
At the same time, 29 states already require health insurers to pay for telemedicine services, according to the American Telemedicine Association. And organizations like the American Medical Association and the Federation of State Medical Boards support telemedicine.
“No one is going into this thinking that they are not going to deliver good care. Everyone is trying to deliver the best possible care under the circumstances,” Dr. Wechsler said.