Opinion : Back to The Future With Tele-Health

When You Discover You Are Riding A Dead Horse, The Best Strategy Is to Dismount ~ Dakota tribal saying"

Change in healthcare is a constant. For those of us sitting at the cusp of burn-out even prior to the pandemic and feeling hollow despite nose to the grindstone work ethic for decades, the Pandemic’s unraveling and fracturing across ethnic and socio-economic lines was just inevitable.

This Pandemic has been a  ‘Paradigm’ shift of historical propensity often likened to the post-World War II climate when global shifts throughout social and economic domains were felt. The overall effect of these post-pandemic upheavals is a ‘coming closer together of the globe in terms of impact. The rise in telecommuting itself has brought state borders and national borders home. We also have a new appreciation for human capital after the mortality wreaked by covid and the great resignation in its wake. Human labor will never look the same again and buildings designed to trap human capital inside them will likely need to furnish other uses for these gilded structures.

Meanwhile, the entrenchment of the Affordable Care Act over the past decade has also matured full circle culminating in the present moment of health care consolidations where the sense is that we are staring with bated breath at the inflection point of a pendulum swing.

The transformative effect of the pandemic on health -care cannot be understated. Take for example this comment from Curai’s blog post written by founder Neal Khosla ‘Provider systems have two primary challenges in adopting digital health products: misaligned financial incentives and a change-averse culture”. The post, it seems,  was written pre-pandemic in the bewitching hours just prior to a global shut-down and couldn’t be truer today. 

https://medium.com/@nealkhosla/on-the-digital-health-conundrum-part-i-7019d6961aae

Companies like  [Teladoc] MeMd [ now rebranded as Walmart Health Virtual Care] Wellvia and [Telemed2u ]are now seen as trailblazing and their founders’ vision as farsighted.

Tele-health also stands to solve the problem of rising health care premiums from health system consolidations following the Affordable Care Act [ACA] 

The  ACA stands as a testament to good intentions gone awry at first. Yes, we certainly insured many more millions and removed the pre-existing condition clause with health insurance mandates. This was a big win. But we also hammered punitive action upon hospital systems - many that went belly up due to insensitive quality measures. We did succeed in pressuring hospital discharges to quicken, and patient bed turnaround times have become efficient. Hospital throughput may have improved but the regulatory measures spelled doomsday for many hospitals, especially in rural areas or states that failed to expand Medicaid.  We may chalk this up to the unintended consequences of the ACA. But what of the quickening health care consolidations that are racking up the cost of health care and moving it beyond the reach of the average family?

What about rising premiums and inflated deductibles? The average deductible and out-of-pocket co-payments and co-insurances are now so high that some populations are opting to drop out of Private health care insurance altogether. Crowd-funded health care and self-funded employers are on the rise. Direct Payment Models [DPC] has moved up the chain from primary care to specialty services. Federally Qualified Health Care systems [FQHCs] are becoming strained.

The deductibles and out-of-pockets are so large that preventive care can be provided at a lower cost [outside of insurance] within these direct payment models. One could get catastrophic coverage alone through Insurance and that would tie up the deal fairly simply. But nothing about health -care is that simple. Human physiology and biology are often unpredictable. Circumstances beyond our control such as epigenetics and environmental toxins can trigger genetic mutations leading to cancer or a chronic autoimmune disorder. Management of these complicated scenarios certainly requires the engagement of Insurance coverage for expensive pharmaceuticals or in health care parlance ~ the infamous Part D coverage.

Similarly, a predictable consequence or ‘fall out ‘from passing cost as well as transferring risk onto patients by health plans is that Patients are not consumers of health care anymore. They are their own health systems. This is possibly the greatest unintended ‘risk transference’ that has come about. Health care used to be a simple transaction between patients and providers [ physicians, pharmacists, hospitals, etc..]. The presence of ‘Risk’ inserted Insurance companies into the mix and has led to the creation of the Modern Health -Care system. So what happens to the value of the insurer when the pendulum has swung so far to an extreme that Patients are assuming greater and greater risk. The burgeoning digital health technology market is perpetuating this trend although the original intent of these technologies was not to transfer risk but rather to render the ‘provider’ impotent.

Patients in this mayhem flock to ‘feel good and ‘self-empowering’ avenues such as alternate, functional and naturopathic therapies that are suddenly more accessible [ and possibly more appealing ] to them than their allopathic or osteopathic providers who are locked and gagged to their  Pharmacy Benefits Management [PBM] and Health Care Systems.   This may be a double-edged sword on the one hand as it turns the patient into an ‘aware consumer’ but also exposes them to poorer outcomes in less validated systems. Many players have entered this vacuum including digital apps and wearable devices.

There are other advantages however to telehealth that are not just limited to remote monitoring platforms.

I DO see the pendulum swinging back in the future to support physician-independent practices and telehealth will enable this further through digital democratization and promoting a continuum of care. Via telehealth patients can maintain a relationship with the same provider across state and national lines and throughout a  lifespan. Eg: a medicare member that splits time in three different zip codes and shares homes with 2-3 children over the years, Or the millennial or baby-boomer that chooses to work in 2 different states or has frequent travel needs. Telehealth adoption was slow in the past decade NOT due to its intrinsic failures or the lack of familiarity of the consumer with digital technologies. There is a sense that the future health consumers i.e millennials, generation -X, and the younger Boomers will likely be at far greater ease with digital interfaces post-pandemic and would even appreciate the convenience of tele-visitations. An ecosystem of telehealth providers is already forging bonds above the brick-and-mortar systems in anticipation of this trend. Not being burdened by swanky offices, buildings, and campuses, this eco-system is free to create contractual arrangements with laboratory and imaging vendors that are top quality across state lines. And the beauty is that it can be accomplished within the bounds of insurance contracts leaning toward value-based models rather than fee-for-service. The ease of telemedicine lends to this model where greater patient touch points are expected with the help of physician-extenders such as medical assistants, physician assistants, and nurse practitioners.

Telemedicine and Interstate Licensing have burst open opportunities and bring immense leverage to delivering services where most needed such as to rural and underserved areas while remaining conscious of the social determinants of health. And not just that. Telehealth even offers hope to young specialists that would prefer to treat rural or vulnerable populations without actually moving their young families out of urban areas. Just as health care has been pushed out of hospitals towards outpatient centers for the last decade, similarly the future trend will see health care falling out of swanky offices and buildings closer to our homes.  This makes sense not just because of the Stay- In -Place policies around Covid but also because our population is in fact aging at home and inside nursing homes. So it only makes sense that the site of healing would move upstream as well whether it be to bring comfort and convenience closer to the home via remote patient monitoring or physician house calls. With the passage of the HITS accreditation by CMS in Feb 2021, it has become clearer that CMS intends to bring chemotherapy closer to home as well.  Biologic home immunotherapies will follow this trend undoubtedly as well.

Policy barriers that stood between efficient, cost-effective, and agile health delivery appear to be coming down quickly and perhaps someday soon we may even welcome an Amazon Pop-up hospital in our backyard or a HIPAA-compliant Siri summoning the physician home. It is exciting to have more stakeholders in the ring as it offers both physicians and patients sorely needed choices and this may not necessarily be a bad thing so long as everyone is playing on the same court and not necessarily under the same roof!

Farah Salahuddin MD

The views expressed here are personal and do not reflect those of any health system or physician group collaborator. 

Feedback and comments: clinic@rheumwithoutwalls.com 

Author

Farah Salahuddin MD Farah Salahuddin MD [ pronounced Salah'din] is the founder at Tele-Rheumatology Medical Associates [dba 'Rheum Without Walls'] where digital health is leveraged to bring Rheumatology closer to the patient's home and with a view to raising the value of specialist care while curtailing burgeoning health care costs. She resides in California and has an Inter-State License [IMLCC] to practice in several US territories. She serves as Rheumatology Consultant for Ochsner Health System and Telemed -2U driving change in rural health settings and serving vulnerable and underserved populations across state lines and across health care systems.