Telemedicine, also sometimes going by telehealth or virtual care, has now been around for quite some time. Over the past few years it has become a popular buzzword in both the startup business world as well as the healthcare administration world. Many seem to want a part of it but most do not seem to fully grasp what it is or how to implement it. While telemedicine is a buzzword in those segments of society, among the actual recipients of the care, the patients, the true knowledge of what it is, how it is used, and the risks and benefits of using it are just beginning to be revealed to and accepted by the general population. Telemedicine utilization is low compared to its availability.
There is no doubt that improved access to care in a cost-efficient, convenient, and safe manner is becoming more popular. This is evidenced by the fact that from 2011 to 2016, billing for telemedicine visits has increased by 643% overall and in rural areas of the country by 960%(1). While these increases seem impressive, the actual overall numbers are rather small compared to the size of our country's population. Going from 2 patients to 12 patients is a 600% increase but is still only 12 patients. Similarly, telehealth being used even a few million times per year in a country of 325+ million is not that impressive of a utilization rate.
Telehealth services are now being offered nearly everywhere. These services are being offered through health insurance plans, employee-benefit plans, through doctor's offices, hospital systems, and through a bunch of services providing care directly to patients at a low cost and bypassing the normal modalities of seeking care.
But when it comes to utilization rates, the actual percentage of patients using the services is generally in the sub-10% range. While 96% of large employers report they will offer telehealth services in 2018, less than 1/5th of employers are experiencing usage rates >8%(2). And while nearly every commercial health insurer is linked to a "preferred" telemedicine service, through gleaning data from SEC filings of the large publicly traded provider, who 23+ million have access to, the utilization rate is only about 7%(3).
So obviously there is a disconnect between availability and acceptance. While one might think that easy access to low-cost medical providers might be a no-brainer, that is not turning out to be the case. There obviously are some other factors that go into increasing the use of telehealth services.
Just like in political elections, some people my be single issue voters and others may look at multiple qualities of a candidate. So too, are some patients single issue deciders (like cost) while others require multiple incentives to try a new healthcare offering. So in order to appeal to a wider portion of the population and win the popular vote, telehealth offerings must address more than just one issue for patients.
Below we will take a look at those factors that should be addressed. Taken together we will call them the KITCHEN SINK and if a telehealth service can address every item in that sink in its service, it will be more likely to effect widespread change and acceptance.
First and foremost, a patient needs to have a knowledge that telemedicine even exists and what it is. Of course, if patients don't even know that an option exists for them, they are not going to use it. Currently, part of the utilization problem may be related to this knowledge gap. Software Advice, found that 83% of respondents had never used telemedicine and 72% were unaware of whether or not it was a service covered by insurance in their state(4). But on the flip side of that, the Virtual Visits Consumer Choice Survey found that 77% of patients are willing to engage in a telemedicine encounter(5). So it falls upon those offering such services to make it obvious to patients when, where, why and how telemedicine should be or will be utilized.
This promotion of the availability and qualities of telehealth must be more than just a banner at the top of a webpage on a health insurer or some other site. It needs to be more than a single mailing, phone call, email, or mention by a doctor. It needs to become such an ingrained component of healthcare such that the knowledge of it starts to displace some of the more common knee-jerk reactions to a need for healthcare such as the more expensive Urgent Care or Emergency Department options. This will require multiple touchpoint with a patient. It is common lore among marketing print that a potential customer needs 6-8 points of contact before they actually become a customer. With as new of a model and workflow of healthcare as telemedicine is, it will likely take that and more to convert the average patient.
We are well conditioned by health insurance to consider whether a given medical provider or service is "in network" or "out of network". Particularly when it comes to high-deductible health plans where the patient is responsible for such a large burden of healthcare expenses before the insurer pays, going "out of network" makes it just that much more expensive before getting some assistance with costs. Even outside of high-deductible plans, copays and coinsurance could be larger, or the insurer may decide that they simply will not cover the service at all. Because of the extra pain involved in going out of network, most health care consumers are pretty attune to staying within the network rather than deal with the hassle. According to healthcarebluebook.com, even a procedure done within network can vary as much as 500% in cost(6). There are many situations where it might actually be worthwhile to go outside of network, and getting care virtually might be one of them if the insurer does not offer or cover it. However, due to the confusing and complicated system that we have, most will play it safe and remain in network. In order to improve utilization of a telehealth service at this juncture in time with our multitude of health insurance offerings, it would be good to make sure that the providers of that telemedicine service are part of the approved "in-network" providers.
For decades, patients have been accommodating and respectful to the healthcare system and medical providers for wasting their time. Making appointments, waiting for appointments, driving to appointments, waiting in waiting room and then in exam rooms, waiting for results and callback, etc. But the patience of the patients is wearing thin. We are living in an on-demand world from movies to banking. Healthcare needs to live in that world too. More and more people are deciding that if their healthcare provider or location does not offer online scheduling, online access to records, and nowadays, online access to a medical provider, then they are more likely to skip that option. The Telehealth Index: 2017 Consumer Survey conducted by American Well actually showed that 1/5th of patients were willing to switch from a doctor that does not offer virtual visits to one that does. The willingness to switch was higher in the under 34 year old group(26%) and the parents with young children group(34%)(7).
Low-cost has always been a selling point for telemedicine. As mentioned above, for some patients that can be influenced by a single issue, cost may just be it. With our healthcare costs being ridiculously out of control between premiums, copays, deductible, and more...a low-cost entry to either get advice on whether or not further care is needed or to actually be able to handle a medical situation is a wonderful thing. For those without insurance or those on high-deductible health plans, cost is often a bigger factor due to the burden accessing healthcare can place on that individual or family. Making the cost of service transparent and reasonable can go a long way to enticing a subset of patients.
However, the current very low cost structure of direct-to-consumer could also be a detriment to telehealth utilization for two reasons. First is the commonly health belief that "You Get What You Pay For". Patients may be skeptical of the quality of a service when it comes in at such a low cost. Many patients are willing to pay more for easy access to their private doctor as evidence by concierge medicine and the rise of direct primary care models. Telemedicine sells itself with marketing words like convenience and quality yet prices itself for the most part in the bargain bin. Based on experience, it is not unreasonable that patients may be a bit wary.
The second reason that low cost may be a detriment to telehealth utilization is the ability to attract appropriate utilization among medical providers. While we are not diving much into provider resistance to telehealth in this article, a low cost method of providing care usually equates to lower revenue. Telemedicine companies promote the ability to work from home and convenient scheduling as a perk, but the reality is that making a living and in particular, sustaining a family with the average take-home pay from providing telemedicine services may be difficult. As a result, telehealth providers are often retirees or just dabbling on the side. Some may be burnt out of standard practicing. While none of this may have any true effect on the quality of care, the lower reimbursement often obtained in this lower-cost care model may have the effect of not attracting some talented medical providers.
The cost issue appears to be a potential double-edged sword when it comes to patient perceptions but thoughtfully and transparently pricing the service based on the patient population being served is recommended. To attract quality medical providers, a telehealth service should also consider its provider payment model.
Low health literacy is associated with less use of preventative care and poorer health outcomes which leads to higher utilization of healthcare dollars(8). With telemedicine, a patient may have the knowledge of what the service is, but may be unable to understand what it is or how it works. Tied into this, would also be tech literacy which can range from access to the technology needed to engage in a virtual visit to the tech know-how of working smartphones, browsers, or other technical equipment.
Addressing health and tech literacy through education, assistance, improving access to telehealth capable devices, and training can go a long way to improve everyones understanding and comfort level with telemedicine.
Experience & Trust
Let's say you go to a restaurant and have an inattentive waitstaff that serves you the wrong food and it tastes terrible, plus it costs a lot. How likely is it that you would use that restaurant again? Exactly, very low. At least with restaurants, there are often multiple review methods you could use before the experience to get a sense of what you are getting yourself into. This is not the case in healthcare. Finding decent information on cost, quality, and others' experiences are difficult to come by.
Patients often go by their own past experience or the word of mouth experiences of others. If they have not experienced telehealth or heard of good experiences with it, they are less likely to use it. To a certain degree, a strongmarketing campaign can overcome of this an instill a sense of trust. But a positive experience is what actually builds the trust for future use.
Trust is very important in healthcare. Trust is built through a good experience but transparency in the credentials of providers, education on how private information is secured, and having ties to local healthcare providers and systems all help in creating trust. Related to trust is a trust that telehealth providers are competent to provide the necessary care. To this end, while there are some significant advantages to allowing for cross-state line medical credentialing, particularly when it comes to provider shortage areas, there are also some potential disadvantages. Many multi-state telehealth services are using multi-state licensed providers, which means that there is a decent chance that the medical provider seeing a patient is not located within the patient's state. While is is fine much of the time, think of what could happen if an out of state provider is not up to date on the lates local outbreaks of E.Coli, Mumps, West Nile Virus or even just how the local environment can affect the health of the patient. Telemedicine legal cases are pretty sparse right now, but that will not remain the case as utilization increases and more chances for error occur. Healthcare is usually local, and should probably remain local when possible.
We know that many patients have fears of engaging the healthcare system. For some is could be a prior negative experience but for others is may be an internal anxiety disorder, a fear of finding something bad, a fear of being exposed to authorities, a fear of being physically exposed, or a fear of private medical issues being overheard or revealed. It may be difficult to identify what a potential patient's internal fears are, but if they can be found and addressed, the chances of bringing that patient in for care increase.
Simple to Engage
This system of healthcare we have is incredibly complicated. Digital health technology has a distinct advantage in the potential to simplify engagement with the healthcare system. Diagnostic devices, personal health data collection, and a personal medical provider can all be accessible from the comfort of home or anywhere else from many devices.
Much in telehealth is still somewhat difficult in that there are multiple platforms and devices that do not work in harmony together. Yet compared to the often complicated methods of the past, telemedicine can simplify the experience by creating a single portal that could access all components of care.
For a select group of patients, it is important to consider their physical capacity and even their mental capacity to engage in a healthcare option. Telemedicine, medical house calls, and quick and affordable medical transportation such as Uber Health all help in minimizing complications for those with physical or mental disabilities that may make self-transportation to a source of care more difficult. There are regulations published that promote accessibility when developing technology. These guidelines are called the 2010 ADA Standards for Accessible Design and should be considered as an integral part of helping to improve utilization of telehealth, particularly for this vulnerable segment with significant access issues(9).
The proximity of a care option can be one of stronger factors in healthcare utilization. Using Google's Keyword Planner Tool designed to help those trying to market their services and products, you can gain some insights into what potential patients are searching for. Common Google healthcare search phrases include things such as "doctor near me" and "doctor in [name of city or town]". Patients are actively searching for options and answers as revealed by using Google Tools such as the Keyword Planner as well as the statistic that WebMD alone had 128 million visitors in the past 6 months(10). Healthcare access can't get much closer than right at the fingertips both for information and actual visitations.
Everyone dislikes having to start from scratch each time they go see a new medical provider. Many of the telehealth service options are also disconnected from in-person care. If a patient is seen by a provider through telemedicine and they need more care than can be provided through that virtual visit, they often are sent back out into the healthcare wilderness to fend for themselves and go make their own appointment for whatever next level of care it was suggested they need.
Connecting patients to telehealth providers, telehealth providers to in-person providers, and patients to in-person providers needs to become a collaborative loop that is not broken. Additionally, connecting patient health data such that information is not lost or unnecessarily repeated makes for a more efficient system.
A telehealth service that is connected to a patient's other care sources as well at their sources of health data is a service that is likely more attractive to engage in for the patient and will help increase utilization.
Nobody likes to be ignored. There are hundreds of telehealth options available for patients today yet utilization rates are lame. In order to win the popular vote with patients, it must be shown to them that telehealth is a natural and integral part of accessing healthcare. For many, it may be the best way to initially engage with the health system and either be advised or treated then and there or connected directly to the most appropriate, affordable, and available local in-person care modality that fits that patient's situation.
In order to win the support of the majority of the patients, a telehealth program cannot just focus on one issue, but instead cover many. Keep the patient at the forefront of the program and throw in as much of the KITCHEN SINK as possible to improve utilization, or risk watching that telehealth service go down the drain.
Sources:(1)Fair Health White Paper, A New View of Place of Service Trends and Medical Pricing, March 2018. (2)National Business Group on Health, Employer’s 2018 Health Care Strategy and Plan Design Survey, August 2017. (3)Teladoc, Annual Report, February 2018. (4)Software Advice, Should You Offer Telemedicine Services?: Patients Weigh-In, https://www.softwareadvice.com/resources/should-you-offer-telemedicine-services/. (5)The Advisory Board Company, Virtual Visits Consumer Choice Survey, June 2017. (6)Healthcare Bluebook, https://www.healthcarebluebook.com/explore-transparency. (7)American Well, Telehealth Index: 2017 Consumer Survey, January 2017. (8)County Health Rankings and Roadmaps, Health Literacy Interventions, http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/health-literacy-interventions. (9)ADA, 2010 ADA Standards for Accessible Design, September 2010. (10)Similar Web, https://www.similarweb.com/website/webmd.com, April 2018.