After my posts on telemedicine were published recently, (this one on Manly Wellness before the pandemic and this one after it erupted, on A Country Doctor Writes, then reblogged on The Healthcare Blog, KevinMD and many others), I have been asked about my views on telemedicine’s role in the future of primary care.
Things have changed quickly, and a bit chaotically, and there is a lot of experimentation happening right now in practices I work or speak with.
Before thinking about telemedicine in Primary Care, we need to agree on some sort of definition of primary care, because there are so many functions and services we lump together under that term.
Minor Illnesses
Many people think of primary care mostly as treating minor, episodic illnesses like colds, rashes, minor sprains and the like. This is an area that has attracted a lot of interest because it is easy money for the providers, since the visits tend to be quick and straightforward and such televisits are also attractive for the insurance companies if they can keep insured patients out of the emergency room. With the technical limitations of video quality and objective data such as heart rate and rhythm, I think this is an absolute growth area for telemedicine. However, with all the other forms but mostly here, fragmentation of care could become a complicated problem. To put it bluntly, if we still expect a medical professional or a health care organization to keep an eye on reports from various sources, such as hospital specialists, walk-in clinics or independent telemedicine providers, they are going to want to get paid for it.
Chronic Disease Management
In actuality, the bulk of the work we do in primary care is manage chronic diseases like diabetes, hypertension, heart disease, obesity, lipid problems, depression, fibromyalgia, asthma and COPD. Many of those conditions are well-suited for telemedicine, at least in between more in-depth periodic hands-on assessments, but a significant portion of patients who suffer from these chronic diseases either lack computer/Internet access or have difficulty using the technology. I still think this is a growth area for telemedicine and in the broadest sense this is really a science-based ”life coaching” in many cases. Here, a good data repository and continuity in the relationship between patient and provider are essential.
Referrals
Another function of primary care is making sure that patients who believe they need specialty care in fact do, and to facilitate appropriate referrals. So many people don’t know what specialty does what, and this division of labor varies even between counties within a state. A patient who needs allergy testing in northern Maine who asks for a referral could travel 200 miles to see an allergist or 20 to see an otolaryngologist who also does that. And where is a podiatrist a more appropriate referral than an orthopedic surgeon? Sometimes you need to physically examine the patient to know where to refer, but not always.
Public Health
Another area where telemedicine, in my opinion, has an obvious role is public health – one of my pet peeves as far as things that shouldn’t be the doctor’s responsibility. Once patients are set up for telemedicine, other people besides the medical providers can be involved: The practice can send health reminder messages via patient portals, provide screening and followups, patient education with nurses and other practice staff or even contracted off-site niche resources. Right now (here I go again…) primary care visits are bogged down with mandated public health issues that fit poorly in typical fifteen minute office visits.
Payment Reform – Don’t Revert
It is hard to imagine that we would return to the belief that in person visits will be the only way doctors deserve to get paid for what we do. I think the last several weeks have established in the public mind that medicine isn’t so different from other service industries that we shouldn’t use the available technology for the benefit and convenience of our customers.
A Country Doctor Writes: 
As always, interesting points to ponder. Hope you and your family are well, and take good care of yourself!
My insurance company started offering telemedicine a few years ago. For a flat fee of $40, you can call a doctor. I have had three occasions where I have used it. The first, I can’t remember the reason for the call, but an appointment was set up, the doctor was supposed to call me. He didn’t, but told the company that he did and I was charged the $40. If he had attempted to call my cell phone would have noted the missed call. There wasn’t one. The second occasion I came down with a cold that was aggravating my asthma while I was travelling. I was told that without an exam there was nothing that could be done. Go to a walk in clinic. The third one I developed cellulitis in my lymphedmic arm on a holiday weekend. I was told without an exam nothing could be done, go to a walk in clinic or an ER. I don’t need to spend $40 to be told there is nothing they can do and send me to a walk in clinic. Telemedicine is useless.
Telemedicine should be a video call.
It was a video call, both times. And the doctors, since it was associated with my insurance company had access to my medical records. They didn’t look, even to see if I’d been previously diagnosed with asthma or lymphedema. They just said, go to a walk in clinic.
😩
If you state you are having an asthma flare you are likely right, however you may be wrong. Is it a mild pneumonia? Do you really need to be on oral steroids or is it a URI? The lungs need to be listened to and telemedicine does not allow for that. They were right to tell you to go to a walk in clinic. Convenience should not come at the expense of appropriate care.
No argument here. I am not a proponent of urgent care telemedicine. It is if anything harder to do than chronic care that way. But look at the startups expecting to get rich on urgent care telemedicine….
I think the difference between what Lisa experienced and what we are seeing now, is I can do A LOT over a telehealth visit with a patient that I know and is established. I can do SO much. I hope the reimbursement keeps up after the pandemic.
While CMS declared equal pay for equal E+M service, commercial payers are all over the map. Our biggest payer is only paying 70% for a given telehealth visit based on EOB reviews.
My career has been mostly Federally Qualified Health Centers; 1/3 Medicare, 1/3 Medicaid, 1/3 everybody else including sliding fee and Obamacare. Typical commercial insurance almost not enough to worry about.
I am a PA in primary care and urgent care and I do not care for telemedicine. Studies are showing that it leads to an overprescribing of antibiotics. I feel it will only worsen as it becomes more common. It will only become more commonplace that people will use the service stating that a child is pulling at the ear and should get an antibiotic and providers will be all to accommodating because they feel market pressures. The same can be said for UTIs and pharyngitis. I have seen providers that are all too accommodating when someone calls wanting an antibiotic without coming in. Too many “minor” conditions can be better treated by appropriate guidelines when a good physical examination is incorporated. Please do not make blog posts without considering this. You are facilitating the breeding of MRSA C. Diff and the like. It is a disservice to the public.
https://www.nih.gov/news-events/nih-research-matters/antibiotics-prescribed-more-often-during-telemedicine-visits
Especially if you don’t have an established relationship with your telemedicine patient.
I would agree that “telemedicine” is here to stay. Video connection through a computer is simply a tool, as is a conversation through the telephone, and communicating via email or text. The most influential factor that has held these tools back is lack of payment for work performed in a FFS, face to face system mandated by archaic insurance company rules, until just recently. However, having an established relationship with a physician who practices comprehensive primary care who utilizes these tools makes a difference. Further fragmentation of patient care by dedicated “telemedicine doctors” is not what we need. We need well trained physicians who can provide ongoing, comprehensive, coordinated primary care and be paid in a manner that recognizes the value of this type of care using whatever means of communication is helpful. Comprehensive primary care needs to move away from a FFS, piecemeal payment system and resist further fragmentation of care.