Telehealth’s Dilemma Is Healthcare’s Dilemma

The telehealth market in the United States finds itself at a crossroads. Direct-to-consumer (DTC) telehealth has matured to the point that on-demand services are (in very broad terms at least) available to most Americans, either via a smartphone app or a kiosk at a retail clinic or worksite.

At the same time, the market needs to pivot from episodic to chronic care. The former is more lucrative; the desire for disruption and access is greater, as more traditional healthcare organizations (HCOs) have set the bar so low. However, the latter is poised to be more transformative, lowering overall care costs and improving care continuity – provided that HCOs, payers, employers, vendors, and patients can all figure out what they want and, more importantly, who will pay for it.

The partnership between American Well and Samsung illustrates telehealth’s dilemma quite well. American Well’s telehealth service is now integrated with Samsung Health, the health app formerly known as S Health that is also now available for all Android devices. Within Samsung Health, users who navigate to the Experts tab can initiate a video visit with an American Well doctor. The app will verify insurance information on the spot, and the visit costs $59, which is what American Well normally charges.

The partnership shows how much DTC telehealth has matured, as it’s now available to anyone with an Android phone. It also shows how hard it is for telehealth to pivot, as both vendors indicated on a recent call with analysts that the partnership will initially focus on episodic and urgent care. A shift to chronic care is inevitable – if for no other reason that few doctors enter the profession to spend all day diagnosing strep throat or looking at weird rashes – but the timeline is unknown.

A big deal, but only if…

American Well and Samsung think their partnership can be the starting point for a multi-channel telehealth platform, one where text messages and video visits are standard components of a longitudinal care plan and integration with electronic health record (EHR) and care management solutions is common.

Whether it is in fact possible to marry clinical and consumer telehealth depends on a number of steps forward that are largely out of the control of American Well and Samsung – more consistent regulations, standardized credentialing, cooperation from EHR and care management vendors, expanded insurance coverage (especially from Medicare), and HCO acceptance of virtual care as a viable substitute for in-person care in certain scenarios.

The biggest factor, though, is payment reform. With more than 80 percent of care in the U.S. still covered under a fee-for-service (FFS) model, for example, American Well and other telehealth vendors (as well as their shareholders) can be forgiven for favoring low-acuity episodic care over untested and unproven chronic care – unless frequent users of episodic visits present an opportunity for member acquisition. (In this case, we mean follow-up chronic care as opposed to in-hospital chronic care such as telestroke or teleICU, where both the use case and the value proposition are much less uncertain.)

A recent commentary wondered if the telehealth sector is headed for a bubble – and another pointed to the dearth of late-stage startup funding deals in telehealth. Add to that clinical studies with differing conclusions about access and ROI, as well as a hodgepodge of regulations, and it might be time to pause and take a breath.

If nothing else, it might be time to admit that telehealth is getting pretty good at broadening access to episodic care but still struggles to address chronic care. The former works for healthy patients who don’t have (or even necessarily need) a longstanding relationship with a primary care physician (PCP). The latter, meanwhile, depends on such a relationship; that’s hard to build if a patient consistently sees different physicians and there’s no record of those visits in a PCP’s EHR. With their partnership, American Well and Samsung are certainly trying, and other vendors would be wise to try as well, but they face an uphill climb.

All that said, telehealth’s dilemma is no different that the healthcare industry’s “one foot on the dock, one foot in the boat” conundrum: Initiate value-based care when and where it makes the most sense, or has been mandated, but stick to FFS in all other scenarios. Framing the telehealth discussion in this larger context should provide some clarity about what must happen to leave the dock and get into the boat.

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Posted in consumer health, Engagement, telemedicine
2 comments on “Telehealth’s Dilemma Is Healthcare’s Dilemma
  1. David Hold says:

    I was reading your article with great interest but I think you should read my comments as we have been at it for nine years. As i could not highlight my comments i put them in quotation marks.

    The telehealth market in the United States finds itself at a crossroads. Direct-to-consumer (DTC) telehealth has matured to the point that on-demand services are (in very broad terms at least) available to most Americans, either via a smartphone app or a kiosk at a retail clinic or worksite.

    At the same time, the market needs to pivot from episodic to chronic care. The former is more lucrative; the desire for disruption and access is greater, as more traditional healthcare organizations (HCOs) have set the bar so low. However, the latter is poised to be more transformative, lowering overall care costs and improving care continuity – provided that HCOs, payers, employers, vendors, and patients can all figure out what they want and, more importantly, who will pay for it.

    “There is the misconception that preventive care is less lucrative as he even indicates that it lower cost and improves continuity. The misconception originates where industry is portraying it as such to be able to hang on to their exorbitant margins and inefficiencies . As our system proves it is simple and affordable.”

    The partnership between American Well and Samsung illustrates telehealth’s dilemma quite well. American Well’s telehealth service is now integrated with Samsung Health, the health app formerly known as S Health that is also now available for all Android devices. Within Samsung Health, users who navigate to the Experts tab can initiate a video visit with an American Well doctor. The app will verify insurance information on the spot, and the visit costs $59, which is what American Well normally charges.

    “Exactly what I have been writing many times about. American Well as well as Samsung think that a video conference is medicine . It is nothing more than an expensive video conference that could be accomplished for nothing over a skype connection. Although the Samsung’s and other manufacturers are trying to capitalize on this as they see the opportunity they missing the concept that is nothing more than a hype and real solutions like ours will be the dominant factors in the very near future. Our head start amazes me every time I read an article how they are spending hundreds of millions on irrelevant applications”

    The partnership shows how much DTC telehealth has matured, as it’s now available to anyone with an Android phone. It also shows how hard it is for telehealth to pivot, as both vendors indicated on a recent call with analysts that the partnership will initially focus on episodic and urgent care. A shift to chronic care is inevitable – if for no other reason that few doctors enter the profession to spend all day diagnosing strep throat or looking at weird rashes – but the timeline is unknown.

    “Although our system can handle both situations we still the only ones that has a solution on the second position that I think is going to fade the first one a irrelevant as I said it is built into our system by default.”

    A big deal, but only if…

    American Well and Samsung think their partnership can be the starting point for a multi-channel telehealth platform, one where text messages and video visits are standard components of a longitudinal care plan and integration with electronic health record (EHR) and care management solutions is common.

    “As they thinking about developing that feature ours has it already.”

    Whether it is in fact possible to marry clinical and consumer telehealth depends on a number of steps forward that are largely out of the control of American Well and Samsung – more consistent regulations, standardized credentialing, cooperation from EHR and care management vendors, expanded insurance coverage (especially from Medicare), and HCO acceptance of virtual care as a viable substitute for in-person care in certain scenarios.

    “And again from the inception of our design we were fully aware of this and as such the system was designed as a preventive health platform and not an EMR although our system can interact with one and download the information to them if they so desire and as such we have the advantage that we do not need any of the above mentioned so called obstacles to implement our system with anybody or anywhere. ”

    The biggest factor, though, is payment reform. With more than 80 percent of care in the U.S. still covered under a fee-for-service (FFS) model, for example, American Well and other telehealth vendors (as well as their shareholders) can be forgiven for favoring low-acuity episodic care over untested and unproven chronic care – unless frequent users of episodic visits present an opportunity for member acquisition. (In this case, we mean follow-up chronic care as opposed to in-hospital chronic care such as telestroke or teleICU, where both the use case and the value proposition are much less uncertain.)

    “This is again the result of many of them designing systems that are not only cumbersome to operate but expensive to implement. Our system was designed on the existing telecommunication backbone and as such besides a smart phone or tablet it does not require anything else besides the normal customary peripherals that also are of the shelf items. As such our system regardless of the present reimbursement environment are not only easy to implement but cost effective. Matter of fact as I say many times our system not only saves money but generates new revenue.”

    A recent commentary wondered if the telehealth sector is headed for a bubble – and another pointed to the dearth of late-stage startup funding deals in telehealth. Add to that clinical studies with differing conclusions about access and ROI, as well as a hodgepodge of regulations, and it might be time to pause and take a breath.

    If nothing else, it might be time to admit that telehealth is getting pretty good at broadening access to episodic care but still struggles to address chronic care. The former works for healthy patients who don’t have (or even necessarily need) a longstanding relationship with a primary care physician (PCP). The latter, meanwhile, depends on such a relationship; that’s hard to build if a patient consistently sees different physicians and there’s no record of those visits in a PCP’s EHR. With their partnership, American Well and Samsung are certainly trying, and other vendors would be wise to try as well, but they face an uphill climb.

    “Here again an very myopic view of the situation that is customary from the ones in the industry who still cannot comprehend the changes that are coming down many of them forced as the good old days of plenty are over. Quite contrary as many studies have proved those who use episodic care are using it out of necessity as many of the established providers are still believe in Santa Claus this are the ones that as has been demonstrated many times in history and specifically in the industrial revolution or disruptive technology are going to be the ones that will be left behind. Just look at the urgent Clinique’s popping up and mini hospitals to address this condition . The second point they are also totally of base is that healthy patients do not look for relationship with a caregiver. One question I would like to ask the members who did this study. When they have a medical condition who do they go to see a video conference doctor on the other side of the world or their PCP that they have been using for years. As I said if it is a cut or a bruise sure but anything more than that healthy patient or chronic we prefer a PCP that we have a relation with.
    IF ANYTHING THIS STUDY PROVES HOW RIGHT WE ARE WITH OUR SYSTEM”

    All that said, telehealth’s dilemma is no different that the healthcare industry’s “one foot on the dock, one foot in the boat” conundrum: Initiate value-based care when and where it makes the most sense, or has been mandated, but stick to FFS in all other scenarios. Framing the telehealth discussion in this larger context should provide some clarity about what must happen to leave the dock and get into the boat.

    • Brian Eastwood says:

      David, thanks for taking the time to pen a thoughtful and thorough reply. Two of your points stand out to me.

      One, I am equally amazed and occasionally frustrated that “advances” are often just new versions of the same technology. Too many organizations – vendors and providers alike – keep striving for the same short-term solution rather than thinking about the bigger picture. Every time I see a report touting phone- and email-based “virtual care,” I roll my eyes. Like you said, it often comes down to not wanting to lose that in-person or episodic care revenue stream.

      Two, I’ve written about the parallel paths of clinical and DTC telehealth in the past, and your comments reminded me to post that link here. This, too, seems to a business-model problem – institutions with no incentive to stop bringing in patients for repeated follow-up visits aren’t going to adopt a virtual visit model (or retail health or standalone in-network urgent care or affiliated direct primary care) until they are forced to, and by then it very well may be too late. http://www.chilmarkresearch.com/2016/08/11/marrying-consumer-and-clinical-telehealth-will-take-work/

      –Brian

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