Convenience, but at what price?
Should convenience be the determining factor for how healthcare delivery takes place?
The question goes to the heart of the issue: How far should we let the “convenience revolution” transform the way healthcare is delivered, financed and researched.
Convenience is freedom and power and is directly tied to the Internet. It has led to the boom in online shopping and has put downward pressure on prices. Once an entity delivers convenience to a consumer it becomes an accepted norm, one that is used as a measuring stick with other sectors and products, including healthcare. When convenience is the only decision-making factor for consumers, the price may be less, but so might the value, while the product or service with the highest value will probably cost more and won’t be as convenient.
The expanding market of urgent care centers, community health clinics and retail clinics came about because healthcare wasn’t convenient. And yet, nearly half the recent patients in the United States say they seek care in an emergency room for non-urgent reasons. In an interview with NPR, Robert Blendon, professor of health policy and political analysis at Harvard’s T.H. Chan School of Public Health, said they go there because it’s convenient. Granted, a good many of these patients chose the E-R because the other facilities weren’t open when they finally decided to go to the doctor. And Blendon said the majority of the patients who use emergency rooms for primary care are not the poor and uninsured, but those covered by health insurance. Hospitals have begun catering to this population, even allowing people to schedule appointments in their E-Rs.
Convenience also factored in on a 2015 study conducted by TechnologyAdvice.com, titled “Do Patients Trust Telemedicine?” It found that more than half the people surveyed said that “more convenient scheduling options” would be one of the things that would make them more likely to use a telehealth service.
Passive remote patient monitoring (RPM) systems promise to keep patients more in touch with their medical conditions and their healthcare providers. Connected to the Internet via WiFi or broadband, the systems email alerts to providers when patients’ vital signs and weight are out-of-whack. Do they perform an important function – to stay on top of a patient’s condition without the patient making frequent trips to the doctor or surprise visits to an emergency room? I fear that RPM convenience masks a healthcare mirage.
A recent study, called “Better Effectiveness After Transition – Heart Failure” (BEAT-HF) in the JAMA Internal Medicine journal, showed there was no significant difference in outcomes among patients with heart failure who used remote patient monitoring tools and those who didn’t. Another study, this one for the Scripps Translational Science Institute, called “Wired for Health,” found no short-term benefit in health costs or outcomes for patients monitoring their health with connected devices. And, studies are showing that the alerts are less than effective unless someone at the receiving end pays attention to them. An article from the Agency for Healthcare Research and Quality (AHRQ) even addresses the problem of “alert fatigue” where you would expect to find the best response – inside hospitals.
Outpatient care settings are not much better. Research shows physicians are too busy to go through the mountain of data, leading to alert fatigue. A new study published in the March 14 JAMA Internal Medicine journal found that doctors now spend more than an hour a day responding to an average of 77 notifications. Some physicians in the study got more than 100 notifications each day – all coming through their electronic health record systems. According to the study’s authors – “a single notification often contains multiple data points” to go through. Combing through notifications eats into the clinical time they could be seeing patients. And the study found that physicians who worked part-time received more notifications for the time they spent with patients than their full-time colleagues.
Expecting to add to this information overload is the healthcare wearable device market, projected to hit $17.8 billion in revenue five years from now. At first, it was enough for an individual to monitor his or her own health data derived from the sensors. Now, people want their devices to connect with their providers and provide them with the data about their health.
Convenience for the most part (and in some places, a shortage of physicians) is driving the current Direct-to-Consumer Telehealth phenomenon. People are tired of making appointments, driving to the doctor’s office, sitting in the big waiting room and then in the examination room in return for ten minutes or less with physicians. And despite the aspect of convenience cited above, most don’t like spending hours in an E-R. They now want antibiotic prescriptions with no hassle, usually at off-hours or at night. They don’t want advice; they can get that for free by googling their symptoms on the Internet. Once they’ve paid $40-60 upfront, they expect a prescription. But the convenience may not translate into value-based healthcare. Antibiotics only work when someone has an infection. Viruses that cause colds, flus, sore throats and earaches (the majority of cases, by the way) need to run their courses, usually taking three to six days.
No use blaming the physicians who work for the Direct-to-Consumer Telehealth companies. These services are attractive and convenient because they can work at home without office overhead. They can earn extra money when they want, and they don’t have to nag patients to pay their bills or wait weeks for insurance companies, Medicare or Medicaid to reimburse them.
On the other hand, the government’s involvement in healthcare has been a major disruption because of the inconvenience it imposes on providers. In order to maintain the level of reimbursements, doctors and their staff must spend hours completing reports each year to justify the type of care they provide their patients. If they don’t, their Medicare payments are cut. It’s no wonder that more and more physicians are limiting Medicare beneficiaries in their practice. An increasing number are moving into concierge or direct patient care (placing a ceiling on the number of patients in their practices and charging them an annual fee) so they don’t have to deal with normal office expenses, accounts receivable, and all that government red-tape.
There is one area of healthcare where convenience pays off in providing access while holding down costs and helping to improve outcomes: clinical telemedicine. Doctors can see and treat patients remotely with evidence-based medicine and without interrupting their workflow. For physicians with satellite offices, there is less “windshield time” driving between them. Using a telemedicine system, a doctor can see patients at two or more locations. Studies have shown that patients who have to make appointments weeks or months in advance with specialists have a higher rate of cancellation than patients who can get into specialists in a timelier manner via telemedicine.
For those who are skeptics, doctors using state-of-the-art telemedicine equipment can examine patients as well as if they were in the same room together. Due to the relatively few days of cloud-cover, Arizona is among the leaders in areas where sun-caused skin cancer is common. Richard L. Averitte, Jr., MD, who has the largest dermatology practice in the state, recently conducted a pilot program to train medical residents to use telemedicine exam cameras in remote communities. He watched their patient sessions via live, real-time teleconferencing. The camera allowed him to see the moles his residents were seeing, hear their diagnoses, and concur with their decisions. The results surprised him. “The images produced by the camera are beyond what I have expected. Not only can very subtle color changes be identified, but also differences in dimension as well, meaning there is almost a three-dimensional appearance to the image in a two-dimensional setting.” For those patients with pre-cancerous and cancerous moles, he scheduled them for surgery when he made a two-day clinic visit to their area.
Kirk Gillis – Vice-President of Accountable Care for Renown Health in Reno – oversees Renown’s telemedicine program. Renown’s coverage area extends from the communities on the eastern slopes of the California Sierras to the border with Utah, throughout the northern half of Nevada – an area the size of Kansas. In an interview with me in 2013, he said, “When you look at the time lost from work, the cost of meals, hotel, care for kids and parents, it costs most of the people who live in the outer edge of our service area $800 to $1100 to see a specialist for a 15 minute to 30 minute [in-person] appointment.” That was the incentive for Renown to embark on a clinical telemedicine program that provides specialty consults to small community hospitals.
Although efforts continue in Congress to modify Medicare reimbursement policy, the government has yet to extend this convenience to all citizens. Doctors who practice in sprawling cities receive no Medicare reimbursements if they see urban-dwellers covered by Medicare due to the geographic restrictions Congress imposed in 2001. So, they have little, if any, incentive to invest in telemedicine solutions.
The VA Healthcare System would certainly be instructional for people who think telemedicine is merely an additional resource that people will overuse. In fact, a study just published in the journal, Telemedicine and e-Health, titled “VA Telemedicine: An Analysis of Cost and Time Savings,” found that clinical telemedicine sessions resulted in an average travel savings for Veterans of 145 miles and 142 minutes per visit, leading to an average travel payment savings of $18,555 per year. The study was conducted at only one of the VA’s 150 medical centers, the VA Hospital in White River Junction, Vermont. A similar study three years ago determined that telemedicine was saving the VA so much money, it stopped charging co-pays for Veterans who use the virtual service.
Certainly, convenience will continue to drive change in healthcare as it should. But the changes made must help us prevent illness or treat it in a timelier manner to lead to a longer and satisfying life. In this tug of war, we need to balance convenience with the benefits of evidence-based medicine.