TeleOutreach or TeleProfiteering

The 2010s have been a time of great claims of value from numerous innovations. While it seems that much is being done to help to improve health access, there has actually been very little change. The new proposals can actually undermine health outcomes and undermine the local workforce that is most important for access to care. Resistance to Telehealth may be futile, but there will be consequences that we need to understand.

When High Tech and High Touch Go Wrong

Telehealth has much surface appeal. High tech with the appearance of high touch has appeal. It seems so simple. After all in the photos or descriptions it appears that all you have to do is just link up and someone magically appears to address your needs.

For the purposes of discussion we can leave behind the discussions of laws, licensures, privacy requirements, payment uncertainties, certifications, and also controversies regarding the quality of telehealth.

There are a number of reasons why telehealth is not all that it seems.

Overutilization and Higher Costs Via TeleProfiteering

Retail clinics have demonstrated that convenience is costly. With televisits there will be a wallet biopsy up front and care only for those who pay up front despite claims of access improvement. 

Repeat customer focus could lead to medication overuses. Those who want their antibiotics day 1 of a bad cold are going to go to telehealth services that provide this.

Ecology of Medical Care says out of 1000 people about 800 have some health concern or symptom each month, 327 think about seeking care, and 217 visit an office (half in primary care). Those who think about profit all waking hours know that they can exploit about 30 more visits from each of three categories - those who have symptoms, those who think about a visit, and those who visit an office. 

The potential is to have as many visits from telehealth as seen in primary care. At $50 - 100 dollars a televisit for hundreds of millions in additional visits a year one can see the attraction to those who devote their lives to profit.

This appears consistent with the rest of the US design for highest cost and lowest yield health care. 

It is also consistent with Fire, Ready, Aim as implementation comes first, then adjustments, and finally studies to document benefits and consequences.

 

TeleOutreach Can Complement Local Care 

Sometimes those who institute telemedicine have a greater understanding of local needs and patient needs and family needs.

Project Echo in New Mexico represents telemedicine linked to local care for the purpose of local care support. Project Echo supports local health care professions who present their patients to University specialists - giving the optimal savings of time and costs while providing teachable moments to boost the capabilities of local nurses, clinicians, and physicians. This allows services to exist locally in areas involving general specialties and some subspecialty care. Project Echo has even been expanded to train local health care teams - helping to keep them locally to deliver and expanded range of services. 

Training of health professional students via Project Echo has the potential to revolutionize training and make it specific to local care. There is great potential in keeping training local and avoiding centralized training.

Specific uses of telehealth have been demonstrated to be powerful for teaching and for specialty services outreach (Project Echo).

Telehealth can save costs and improve access in conjunction with home care for complex homebound (usually Dual Eligible) but the constructions of beneficial telehealth are entirely different compared to convenience telehealth which is more appropriately termed TeleProfiteering.

 
Determinants of Health Falling Down By Design

Telehealth can ships dollars away from places that need dollars to places with higher concentrations of dollars, workforce, and services. Jobs, economics, and social determinants of health represent the investments in people and communities that are the key to improved health outcomes. More fertile US soil is required for improved health and health care interventions.  Dollars not sent due to lower payments represent discrimination. Dollars shipped out of town translate to fewer dollars circulating in a town.

Improved health outcomes require changes in local social determinants, local environments, local resources, local jobs, local income, local organization for care, and local behaviors.

Telehealth is a clinical intervention and as such can only provide a small less than 15% influence upon health outcomes. This is likely to be high cost relative to benefit not much different from other clinical interventions.

Telehealth Represents A Policy or Design Change

The changes result in winners and losers. No change works well for all. Telehealth concentrates dollars into the hands of those investing in telehealth. Clearly there will be many smaller players and eventually only a few bigger players. The winners are likely to be the same corporate profit conglomerates who see new opportunities for profits.

Potential TeleProfiteering Abuses

Telehealth (or retail care or urgent care) can be abused or overused as with retail clinics that increase convenience and increase costs. It can take the easiest patients/conditions and can leave the most complex for local providers.  

And HIT, EHR, digital, and telehealth can be outsourced outside of the United States. Shipping jobs outside of the US is a really bad idea to improve social determinants where needed.

Telemedicine is an example of high tech that promises much but can fail to measure up from the local perspective.

Telehealth Cannot Solve Deficits of Workforce

The problem of access is still the problem of insufficient workforce across primary care, mental health, and basic services. There is still a requirement for workforce. Trained team members are still needed to interact with patients in need of care.

Telemedicine only changes the location of the workforce. Not surprisingly the telemedicine design results in more workforce where workforce is concentrated and less workforce where workforce is lacking.

We still have overall deficits of primary care and mental health workforce because of decades of payment too low. Telehealth cannot solve deficits by design and could make them worse.

Telehealth is not a specific workforce solution. It is a different venue.

But of course this will not prevent the promotions of telehealth as a solution for workforce.

TeleOutreach is a solution that builds and supports local workforce. TeleProfiteering does not.

Designs that fail for local remain a problem for local

Who Benefits from Telemedicine?

Telemedicine benefits those who supply the equipment, software, and connections. The media, particularly the digital promotion media profit from Telemedicine considerations. Not surprisingly promotions of telemedicine proceed from similar sources. 

Large systems and academic institutions can benefit from telemedicine. This can be set up to benefit local needs or help concentrate dollars where dollars are already concentrated.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

Martin Luther King, Jr. 

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Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior -  the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity  

Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care 

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

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