- A recent study found that a mobile health platform can cause an increase in office visits and a decrease in new business. Now telehealth advocates are saying that study could actually help the industry.
Conducted by researchers at the University of Wisconsin and the University of Pennsylvania, the five-year study found that a health clinic’s telephone-based e-visit platform boosted office visits by 6 percent. This meant that providers spent more time with those patients in the office, and ultimately led to a 15 percent drop in new patients.
Telehealth advocates were quick to point out that a phone-and-e-mail-based service is just one kind of telehealth platform, and its advantages and disadvantages have been heavily debated for some time. They also say this study proves that providers need to plan carefully and integrate telehealth into the care delivery routine to make it work.
Ralph Derrickson, president and CEO of Carena, a Washington-based telehealth company that focuses on branded services for providers, says the study focuses on one health clinic using a mobile health platform that has evolved considerably over the past few years.
“It is within the past couple years that telehealth has really taken off as a way to change care delivery,” he said. “When telemedicine is offered inappropriately, outside of the health system, or with inadequate clinical decision support for providers, similar to the University of Wisconsin study, utilization and costs certainly could increase. This argues for the importance of responsible and robust telemedicine programs that prioritize patient safety and quality care delivery above all other metrics.”
Kevin Smith, chief clinical officer of Zipnosis, questions whether the e-visit platform was designed to encourage follow-up care.
“Regarding e-visits resulting in an increase in office visits, the authors imply that the efficiencies gained from the e-visits are essentially nullified by the subsequent office visit,” Smith said. “In most cases e-visits are offered to provide convenient access to care or guidance for patients. Perhaps the e-visit served to appropriately move patients from the virtual care setting to the clinic setting. Were the subsequent in clinic visit for the same condition or concern as the e-visit? This was not clear.”
Like Derrickson, Smith noted the e-visits studied took place between 2008 and 2013.
“There have been many advances in e-visit awareness for patients, health systems and clinicians as well as improvements in the delivery platforms since then,” he said. “The authors do not delineate whether the e-visits were simply email exchanges or more sophisticated structured online patient interviews.”
For a contrary point of view, Smith pointed to a May 2017 report prepared by Carrot Health, which found that one of its health system using a Zipnosis platform could expect to retain a quarter of the consumers it sees as patients, with an expected revenue of about $3,000 per patient in the 12 months following the virtual visit.
Drawing those projections out, Zipnosis CEO Jon Pearce and Kurt Waltenbaugh, Carrot Health’s founder and CEO, estimated in a white paper accompanying that study that a health system seeing 1,000 new patients through a telehealth platform could realize $300,000 to $1.2 million in revenue, based on conversion rates of 10 percent and 40 percent. For a health system treating 35,000 new patients, that might add up to between $10.5 million and $42 million.
“The disparity between these findings and those of the (Wisconsin) study may be related to factors such as patients’ changing comfort level with online care delivery technology and the modality of care delivery, among others,” Pearce said recently.
This isn’t the first study to question the value of telemedicine, telehealth or mHealth. Earlier this year, a RAND analysis of claims information from a health plan offering direct-to-consumer telehealth to its member in 2012 found that only 12 percent of those visits replaced office or hospital visits, yet 88 percent represented a new use of existing services.
“The study found that for each episode of acute respiratory infection, the cost of telehealth services were about 50 percent lower than a physician office visit and less than 5 percent the cost of a visit to an emergency department,” the researchers said. “However, the savings from substitution was outweighed by increased spending on the new use of medical services. The study estimates that net annual spending on acute respiratory illness increased by $45 per telehealth user.”
“Like some other new patient care models that promise to cut costs and reduce the hassle of receiving medical care, it appears that in some cases, direct-to-consumer telehealth may increase spending rather than trimming costs,” said J. Scott Ashwood, lead author of the study.
The key phrase there may be “in some cases.” Other studies have found the mHealth or telehealth can replace the office visit and improve outcomes when directed at specific populations, like those with behavioral health issues or chronic conditions.
The Wisconsin study, spearheaded by the Wisconsin School of Business at the University of Wisconsin-Madison grapples with the idea that a phone call or e-mail exchange between a doctor and a new patient may not an effective method of care.
“Offering e-visits seems like a great way to save time and money by reducing the need for office visits because routine questions or updates could be done via email,” Hessam Bavafa, an assistant professor of operations and information management at the Wisconsin School of Business, said in a press release. “The problem is that healthcare is much more complicated - patients may overreact to minor symptoms or not be clear enough in describing their situation and that leads to doctors feeling obligated to schedule an office visit. The resulting office visits can eliminate any efficiencies gained from e-visits systems.”
Bafava told Wisconsin Public Radio that e-visits don’t generally lead to better clinical outcomes, nor are they beneficial to doctors. He said his study found that doctors were spending an extra 45 minutes per week on office visits, and he didn’t study how much extra time doctors were using to respond to e-mails.
He also noted that telehealth isn’t going away. When the study was launched in 2008, only 15 percent of the health system’s patients were using e-visits, and the health system was averaging 50 mHealth communications a month. At the end of the study, the percentage was much higher and the average number of e-mails per month was 3,000.
"I think what our study does is paints a picture of what is currently happening with the current form of patient-doctor interactions,” he told WPR. “And I think what health systems can learn is how they should target these e-visits - maybe identify patients that e-visits may be saving time for them, and identify patients that these e-visits are not saving time for them and are triggering visits for them. So, that basically using them more wisely would be the takeaway for me."
A study reported in Health Affairs in December 2016 also came to that conclusion.
That report, prepared by Ateev Mehrotra, a hospitalist at Beth Israel Deaconess Medical Center and healthcare policy expert at Harvard Medical School, and Lori Uscher-Pines, a researcher for the RAND Corporation, found that a telehealth program can increase the workload for specialists and healthcare providers in underserved areas simply because the increase in quick consults at the front end may add to the number of in-person visits at the back end. This could stress overworked doctors and nurses and add to the wait time for an in-person visit, particularly in health systems that aren’t managing their traffic effectively. And it could keep underserved populations from getting the care they need.
“They offer telehealth capabilities to primary care providers who are frustrated that local specialists won’t take their patients or have long wait times,” the two researchers wrote. “In the environments in which these two programs operate, telehealth seems to have so much promise. However, we learned in our evaluations that bringing in telehealth won’t reduce the burden on the dysfunctional healthcare system. By identifying problems that require longitudinal care, telehealth may actually stress the healthcare system further.”
Derrickson said this proves that health systems have to choose carefully when beginning a telehealth platform.
“Consumer-facing platforms, whether health system-developed or vendor-developed, could result in fragmentation of care if not integrated with a health system’s total continuum of care,” he said. “A vendor-specific platform that is aligned with a health system’s objectives and care offerings helps ensures that providers will be able to deliver high-quality care virtually, and will be able to seamlessly route patients to appropriate in-person care options locally, when clinically indicated. A health system-developed platform doesn’t inherently result in quality care; if not developed with rigor, such a platform would not empower patients or providers.”