The case for a hybrid approach to direct-to-consumer telehealth

DTC telehealth has a definite place in value-based medicine, but providers should be wary of fragmentation issues that may arise from episodic care.

As medicine grows ever more centered on the patient experience, efficiency, and value, direct-to-consumer (DTC) telehealth is taking off. There were a reported 1.25 million DTC telehealth visits in 2015, a trend that is fueled, to some extent, by the belief that virtual DTC care leads to major cost savings because it can replace visits to the doctor’s office and keep patients out of the emergency room.

Yet, because most virtual DTC care is episodic, occurring outside of a patient’s trusted health network, multiple clinical and financial issues can arise when patients and providers tap into this modality. Healthcare organizations and patients should be aware of potential disconnects when utilizing DTC telehealth, and make sure the proper checks and balances are in place.

Addressing the challenges to virtual DTC care
DTC virtual care offers numerous benefits, a fact my family knows from personal experience. My daughter experienced a severe skin rash while our family was on vacation in Hawaii. She was miserable. However, a call to a DTC telehealth service connected her with a highly skilled physician who rapidly diagnosed her, prescribed her medication, and essentially saved us a trip to the ER. We were back in vacation mode in no time and thankful for the positive care experience.

This kind of transaction is ideal, but it isn’t typical.

When patients reach out to physicians who are employed by “dial-a-doc” type services, they’re engaging with professionals who often have limited access to patients’ personal health records. Records from virtual visits can either be siloed, never to be seen again, or because most EHRs aren’t interoperable with telehealth systems, virtual episodes of care aren’t always documented in a way that is searchable (in our experience, they’re often documented as fax-based attachments which really are not “integrated” with the EHR). So, if the telehealth consultation contains critical information, the patient’s regular physician may miss it. Similarly, a virtual DTC doctor is at risk of giving inaccurate information or an incorrect prescription because he or she doesn’t have the patient’s complete health record immediately available.

There are also potential quality issues that arise with DTC telehealth services. For instance, a health network overseeing a patient may not have access to background information on the physicians who are employed by a DTC telehealth provider. The physicians are outsourced through the DTC vendor, and may not offer care that meets the standards of patients, insurers, or other stakeholders in a given health network. Many of these services are trying desperately to keep patient visits to 5 minutes or less to reduce costs.

Case in point: In August, a family friend was bitten by a fire ant when she was traveling through rural South Carolina to watch the solar eclipse. Shortly thereafter, her face, neck and tongue swelled, indicating a severe allergic reaction. After pleading with strangers for Benadryl, and finally securing medication through a 12-year-old Girl Scout, her condition improved. Upon arriving home, her husband urged her to “play it safe” and dial into their insurer’s virtual DTC service to be certain she shouldn’t still head to the ER. After paying a $40 copay, my friend connected via videoconference to a physician.

Unfortunately, the physician ended up raising more questions than he answered, flip-flopping between recommendations to “take more Benadryl every 6 hours,” or “maybe every 12” and to “double her dosage,” or “take just 12mg.” Before the session ended, the physician had changed his mind several times. The patient left the consultation even less confident than when she’d encountered the Girl Scout. The final recommendation from the less-than-three-minute consultation was “try not to get stung again before you can see your primary care doctor.”

She did make an appointment with her PCP, and had requested online that the telehealth service send her encounter record to her regular doctor. But when she arrived for her appointment, her physician claimed it never came through. Her physician chuckled when my friend recounted her telehealth visit and wrote her a prescription for injectable epinephrine.

As this example illustrates, even if your face isn’t swollen like a balloon, every interaction between a patient and physician represents a crucial part of your medical history and needs to be in your medical record.

This example also sheds light on the potential for financial waste when virtual DTC care isn’t properly overseen — especially in an ACO or similar risk-based care model, which relies on care coordination. According to a study published in the March 2017 issue of Health Affairs, DTC telehealth does increase access by making care more convenient for certain patients—but it may also increase utilization and healthcare spending if it isn’t done correctly or while adhering to quality practice guidelines. For the study, researchers analyzed commercial claims data on more than 300,000 patients between 2011 to 2013 to explore utilization and spending for acute respiratory illnesses. By the end of the study, they found that net annual spending on acute respiratory illness increased $45 per telehealth user.

The hybrid solution
Even with its challenges, virtual DTC care can still play an important role in value-based care by helping to increase patient access and engagement, boost outcomes, and save money. The key to reaping these benefits is doing a better job of managing telehealth services at the highest levels.

A hybrid solution should be hospital and health system-led, augmented by integrated virtual DTC services.

The need for quality cannot be emphasized enough. Having a solid physician-vetting system to broker telehealth interactions can help avoid potential communication mishaps and wasted virtual visits. Hospitals, for instance, need to investigate quality metrics such as physician call times, prescriptions, or satisfaction ratings to make sure their telehealth DTC partners meet their standards.

Finding ways to bridge fragmentation through technology is also essential to maximizing the benefits of virtual DTC care. Leveraging telehealth networks that can integrate with EHRs and other patient care systems can facilitate better care. At the very least, healthcare providers need the ability to securely fax or email information about a telehealth consultation to one another – and ideally, implement deep EHR integration where patient data is shared bidirectionally in real time for true care coordination.

Healthcare organizations should also consider ways to capture patient revenues through virtual DTC. For example, if a patient utilizes virtual DTC services that are overseen by a health organization, but doesn’t have a regular PCP, the health organization can help to assign one that works within the preferred network.

When virtual DTC care is integrated correctly within a larger healthcare network, with careful consideration to quality, it can work well to deliver value. Moving toward the goal of value-based care, healthcare providers need to look at the bigger picture, and ask whether the systems we rely on to improve quality and efficiency are being leveraged properly.

Mike Baird is CEO and co-founder of Avizia, which partners with providers to deploy and power system-wide telehealth.

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