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telehealth, best practice, health care inequality

It’s no secret that the COVID-19 pandemic has increased the reliance on telehealth. Physicians and medical systems valiantly adapted to the technology to help Americans get care without risking COVID-19 exposure, and the already booming sector got a shot of steroids.

The rise in telehealth utilization is driven by improved access, decreased cost, and convenience, and many studies have demonstrated that patients using telehealth are generally very satisfied and willing to use the services again. (R I Med J. 2013;103[1]:35; https://bit.ly/3aLgd7A). The direct-to-consumer sector, currently the most popular form of telehealth in the United States, has seen a meteoric rise in demand. Teladoc, one of the largest direct-to-consumer telehealth companies, recently reported visits at nearly 10.6 million for 2020. The company had 575,000 visits in 2015, a five-year growth rate of about 1800 percent, and year-over-year revenue grew 98 percent. Teladoc projects 2021 revenue to be $1.95 billion to $2.0 billion. (Teladoc. Feb. 24, 2021; https://bit.ly/3eAEXAr.)

Consumers have become accustomed to using telehealth, and it was only a matter of time before they expected technology to decrease lines and wait times for medical visits, just as it has in every other industry. Even in the ED, where there are no appointments, patients and hospital administrators expect care and dispositions to be quicker than ever. Telehealth is here to stay, so how do we shape it to make sure it works for the American public?

Many people assume that telehealth is being used to increase access to care, especially for rural and underserved communities, but nothing could be further from the truth. It seems to be adding to our existing health care inequalities instead of fixing them. Studies have shown that older patients, non-English-speaking patients, women, Black, Latinx, and low-income patients (median household income below $50,000) are using telehealth at lower rates. Limited access to reliable internet, inability to access a connected device, and lack of reliable cellphone data plans are barriers for these populations. (JAMA Netw Open. 2020;3[12]:e2031640; https://bit.ly/2PrRcH3.) But I believe that the telehealth providers’ business models are also at fault.

Advances in technology bring opportunity. It seems, however, that we have attempted to adapt the technology to our conventional medical system instead of using it as an opportunity to improve the status quo for marginalized members of society. Telehealth technologies can be purposefully designed to decrease overhead significantly by automating administrative tasks. This creates an opportunity to pass the savings on to the consumer while still creating a profitable business model.

Driving down the prices to make telehealth accessible for self-pay patients can increase access to care for those failed by the conventional medical system. Removing insurers from the equation can further decrease the administrative burden and therefore the overhead costs while also reducing the cost of care to the medical system. Cost containment without rationing or limiting care? Sounds like a win to me.

Unfortunately, most of the larger telehealth companies are publicly traded or founded by venture capitalists looking to enter an emerging market. These companies are designed to be as financially efficient as possible, and access to care and quality of care seem to be an afterthought. Sound familiar?

At their worst, some of these companies have practices that are completely unethical and create barriers to care that risk alienating the populations that could stand to benefit the most from telehealth. Many offer low-cost medical services, for example, but then force the patient to use their pharmacy and refuse to send a prescription to an alternative pharmacy. If that company’s pharmacy does not take the patient’s insurance, the patient is forced to pay out of pocket for the medication or pay to see another provider.

Other telehealth providers take it a step further and force the patient to pay an annual subscription for their prescription. A patient who stops taking a medication still must pay for it until the contract is over. Many telehealth providers also do not offer an option where a patient can speak to a provider, and the interaction is solely via questionnaire and secure text messaging.

Physicians need to be at the forefront of telehealth to fix these issues. We need to make sure that we work to create telehealth options that offer a quality of care similar to conventional medical practices while using the technology’s efficiencies to rethink the business of telehealth.

If we do not take the reins, the health care system’s consolidated corporate mentality will continue to spill over and shape telehealth’s future, and we will have missed an enormous opportunity to fix some of the problems that plague our health care system. What we need are ethical physician-led telehealth companies with business models that allow the uninsured and underinsured access to care. Who’s with me?

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Dr. Bustinis an emergency physician at Tallahassee Memorial Healthcare and is a founder and the chief medical officer of OvaryIt, a telehealth company determined to get women access to contraceptives.