Episode 4 - Telehealth: The Future of Health Appointments? ft. Ateev Mehrotra, MD, MPH

Lauren Jett: You’re listening to “Leading Voices in Health Care Policy”, a podcast brought to you by the department of health care policy at Harvard Medical School. I’m Lauren Jett.

In department news:

Assistant professor of health care policy and medicine Zirui Song has received the Society of General Internal Medicine Milton W. Hamolsky Jr. Faculty Scientific Presentation Award and the International Society for Pharmacoeconomics and Outcomes Research Bernie J. O’Brien New Investigator Award

Thanks to an anonymous $2 million donation, the Ruth L. Newhouse professorship has been made a full professorship. Associate professor of health care policy Anupam Jena was the inaugural incumbent of this professorship when it was established in 2016.

Associate professor of health care policy (biostatistics) Sherri Rose has been awarded the Harvard Medical School Young Mentor Award.

Today we’re speaking with Dr. Ateev Mehrotra, an associate professor of health care policy, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center. Thank you, Dr. Mehrotra, for speaking with us today.

Ateev Mehrotra: Thanks for having me.

LJ: So recently we’ve been hearing a lot about telehealth- you’ll see commercials about people video chatting with their doctors and are you can schedule different types of appointments through various apps and websites. So what type of appointments would you say have seen the biggest increase in telehealth use?

AM: I’d say that there are three big bins where we’ve seen the largest number of visits at least with telehealth or telemedicine- the terminology can be a little loose in terms of that. The first is use of telemedicine to be a mental health specialist: psychiatrist, psychologist, social worker. In particular the Medicare population, that’s been the predominant use of telemedicine.

The other one has been people have termed, I don’t really like the term, “direct to consumer medicine”. This is what you might see ads for. These are companies such as Teledoc, America Well, Doctors on Demand. Through an app or on your computer you’ll go online and you will visit 24-hours a day, seven days a week. These are kinds of issues that people address such as “I’m worried I might sinusitis, I might have this rash, a urinary tract infection” are kind of common things that you will see fro that

The third area, maybe what people have seen over the last year or so is where there’s been a big advertisement, sometimes provocative ads. Those have been for things such as Get Roman is one company, where there will be issues for things like erectile dysfunction, contraception, acne, hair loss. Which are issues where people- there are a couple of drivers: the convenience but also the stigma associated with, so patients may not want to go to their regular doctor for these issues but they feel much more comfortable going to the internet. And though we don’t have great numbers there, there’s a sense that there’s been a substantial growth in the visit to those kinds of companies who are in disadvantaged populations. Often they’re discussing rural communities- you live in a community and you need to see a psychiatrist but there’s no psychiatrist for hundreds of miles away. That is often been what we’ve thought has been the greatest sell for telehealth, and really where I feel the area where people can benefit the most.

The issue that your question touches upon which is some controversy is that in some forms of telehealth the most common users, for example in direct-to-consumer telemedicine, are people who are living in big cities who have plenty of doctors around. I won’t deny that those people sometimes struggle to get into their doctor, you could live here in Boston where we are, and we have a lot of doctors but it can still be a pain to get into the doctor. But, nonetheless that is often where in some forms of telemedicine we’re seeing the greatest growth and therefore the somewhat substantial concern because the concern that has been raised is “yeah, all these are people are going getting more care, but is it really improving their health?” or is this “overuse of healthcare”?

LJ: If you’re doing a telehealth appointment for a physical ailment, you may eventually have to go into an actual doctor’s office, right?

AM: How telehealth is deployed is all over the map. In some particular circumstances there are telemedicine companies that focus on mental health, stroke, other conditions where the only way you can get care is via telemedicine. So if you need to be examined or you need a test they’re going to do a handoff to someone else. They’re going to be saying “okay well you need to- I’m worried about your abdominal pain, you need a cat scan, you need to go someplace else.” They’ll either tell you to go somewhere else or they’ll help you facilitate that. There are plenty of patients whose first stop in the health journey is telehealth and they will go on someplace else.

In other cases, it’s the same health system. So for example, let’s say the Cleveland Clinic and you do a telehealth visit, a Cleveland Clinic provider might say to you “well, I think you need to see somebody in person and we’ll get you to a Cleveland Clinic provider. That’s a distinction that’s often made is it is purely telehealth or is it also a combination? We’re still trying to figure out what’s the best model, both, from an economic perspective and also clinical outcomes. The theoretical advantage of having it all under one umbrella is that the notes and test results etc. are freely exchanged among providers while it’s harder if they’re two separate organizations.

LJ: Do most insurance companies cover telehealth appointments? And if they don’t, are there any signs of a shift to cover more of the telehealth appointments?

AM: What we’re seeing is- first the answer is that most insurance companies covering some sort of telehealth and it is a very confusing landscape for the American public right now. In some cases it’s a little but more straightforward, like Medicare has rules, but in many cases it also depends on the state you live in, almost half of states have passed laws mandating coverage. So you could be in Colorado and you’d have to get coverage for this, but you could be right across the border and not covered. So it gets confusing from that perspective. The other place that changes is the employer. If you’re getting the insurance through your employer, your employer decides whether you get telehealth or not. They introduce it as an added benefit, so it’s not the health plan deciding, it’s your employer saying “yes, I think we should offer this to our employees.” It’s interesting, almost 85% of large employers are now offering some form of telehealth to their employees. It’s becoming more and ubiquitous.

LJ: As more people move towards telehealth or get interested in telehealth, is this going to affect the regular in-person health care? Do you think that smaller practices that don’t get involved in telehealth might suffer?

AM: We are, I would describe it, as still early in our journey of how this technology is going to be incorporated into regular practice. We don’t know exactly. And I think it’s going to vary quite a bit on the clinical conditions we’re managing. Are we managing patients in an ACU versus telehealth versus a cold? That’s going to depend a little bit on how this all plays out, how it’s going to interact with regular care.

There are a couple of things that I might emphasize. The greatest growth in many areas of telehealth that we’re seeing are from private companies. They really grew, just in terms of sheer volume. It reflect the fact that if you’re doing something and that’s all you’re focused on, you do it really well and you get the numbers up. What we see in a lot of the health systems is they’re kind of dabbling, and in terms of just sheer number of visits, they don’t provide that much. They’re trying to figure it out, how it’s going to play out, so we don’t have a clear-cut answer to your question.

One thing that I do think it’s important to emphasize is that telehealth has been promoted as a way to again give access to underserved communities. While the technology can connect a provider who’s hundreds of miles away to a patient in a community, you also have to have the provider’s time. One thing that we have clear in the health care system is that you can go to the doctor in a community like Boston that has a lot of doctors and you can go to a rural community where there aren’t that many and they’re all very, very, very busy. I don’t see, at least in the short term and probably not in the long term, that all of the sudden someone’s going to go out of business because they just don’t have enough volume because everyone is just getting telehealth. Doctors in this country are very, very busy, and if anything I think that major concern is not that people are going to not have enough to do, but rather I think that the main concern that’s going to be an issue is going to be that we have the technology to connect doctors to a rural communities, but we don’t have doctors that have enough time to provide that care because they’re already so busy in their regular clinics. That’s  a major issue that people don’t often discuss when we’re debating the merits of telehealth.

LJ: Do you see a future where patients can take some samples at home and then send them to the doctor or lab for testing so they can get results without having to leave their home?

AM: We are seeing a number of startups that are trying to explore that idea. Maybe to just take a step back- one of the tensions that comes up with telehealth is how much can you really do via video encounter? And all, just to be very concrete, some of the research that we’ve done has raised concerns that in many cases children and adults are being diagnoses with strep pharyngitis and that no one’s swabbing the back of the throat. Let’s be very clear, to do that on a smart phone or a computer camera, to be able to look effectively at the back of the throat, is difficult. You’ve got a screaming kid, you can’t really do it that well, the mom is struggling to have the kid there. As well as just a physical examine, just physically examining the back of the throat is not enough to swab the back of the throat with a rapid strep test. That has raised concerns that there’s overuse of antibiotics and misdiagnosis via this technology. The question is raised for strep throat and many other conditions where testing is the standard of care in 2019, can we facilitate that patients get the test at home? There are a number of startups and companies that are introducing this. So that model that we’ve seen at least so far is that you go to your local pharmacy, your CVS, your Walgreens, your Rite Aid, there’s, just right below the aspirin or something, the rapid test at home. You grab that test- and now it’s sometimes harder or easier. If you’re peeing in a cup it’s pretty easy, swabbing your kid’s back of the throat might be a little harder, but you do so and a read-out comes out saying four three eight. And you use that read-out with a telehealth encounter, so then you go and have a video or some other encounter with a physician, but then you include that number or test results. The thought is that combining these simple tests at home with the telehealth encounter is going to lead to higher quality of care. It isn’t the norm by any means right now, it is some place where we’re headed.

LJ: Thank you so much for joining us today. I’m really interested to see how telehealth continues to grow and change.

AM: Well thanks so much. It’s a really fun journey to see how telehealth is evolving.

LJ: That’s all for this episode of Leading Voices in Health Care Policy. From the department of health care policy at Harvard Medical School, I’m Lauren Jett.  For more of the top news and updates on health care policy, visit the HCP website at hcp.hms.harvard.edu and be sure to follow us on twitter at HMSHCP