Michael Barnett and others published a short research letter at JAMA yesterday.** They looked into how telehealth is being used.
Use of telemental health increased significantly faster in counties with no psychiatrists (P < .001 for interaction) (Figure) and in states with comprehensive parity mandates (P = .02 for interaction). In contrast, growth of primary care telemedicine was not associated with primary care physician supply (P = .76 for interaction)
The big findings from this paragraph are:
- Telehealth is used a lot for mental health visits when there are no local mental health providers
- Telehealth is used a lot when the state supports adoption
- Telehealth is not used more for primary care in counties with low PCP supply
The first two results seem intuitive to me.
The last result is surprising. I would have expected telemedicine to be used as a PCP substitute and complement in counties where there are few PCPs. I would have expected that areas with few PCPs would have seen the most telemedicine for PCP services.
Telemedicine often described as big specialty care in rural populations, but we saw a different pattern:
– 83% of telemedicine users in lived in urban areas
– 53% of telemedicine was for primary care (eg colds) and 39% was for mental health
– Only 8% for everything else!— Michael L. Barnett (@ml_barnett) November 27, 2018
Primary care telemedicine is being used for urban convenience. And that can be valuable as hell when there is a known minor problem where the desired outcome is either a professional saying that something is “OK”, “OK once you get a cheap prescription” or screens out bad, low probability outcomes. If I could have taken my kids to telemedicine visit in order to get a doctor’s note saying that they could return to daycare after they were sent home with a runny nose, I would have done that in a second even if the co-pay was the same or higher than an in-person visit.
Right now, telemedicine for primary care is not filling in for care deserts in low provider density regions. It is doing that for pysch services.
I wonder how we should think about telemedicine for primary care? Is using the framework by Rand’s Martsolf used for urgent care clinics where they are not reducing costs from ER visits on net but serve as a service for the worried well appropriate? I am very curious about the differences in marketing, presentation and patient experience for the psych utilization compared to the PCP utilization as the psych services seem to be working as a substitute for humans in rural areas.
Telemedicine is a place where we’re going to spend a lot of time and money on over the next decade so figuring out how it is working is critical.
** Barnett ML, Ray KN, Souza J, Mehrotra A. Trends in Telemedicine Use in a Large Commercially Insured Population, 2005-2017. JAMA. 2018;320(20):2147–2149. doi:10.1001/jama.2018.12354
John Harrold
My kid would get sick. Then I would get sick. He would be fine after a few days buy I would end up with a sinus infection. My PCP would happily prescribe a Zpack which would clear things up but only if I would come in and see him. This happened every two months and I would have to work it into my schedule or take half a day off work.
Teledoc is much more convenient. Go to the website, put in a request, someone calls you, and you stop by the pharmacy on the way home.
dr. bloor
How much of this might be a supply issue? Primary care practices are usually pretty booked wherever they exist, and may not have the motivation or resources to start taking on cases in the hinterlands.
Butch
When I was still covered under a corporate policy telemedicine was an option and I’m rural so it would have been convenient, except that a televisit cost more than twice the co-pay for a visit to a doctor’s office, so I never even considered it. Unless the provider you’re speaking with is already familiar with you, it also seemed like you’d spend more time explaining yourself than you would with your primary care physician. (I’d hesitate about a diagnosis from someone who had never seen me – but maybe that’s not its intent?)
MomSense
@John Harrold:
Teledoc is also really useful during a blizzard.
NeenerNeener
We’ve got Telemedicine, but my last two emergencies involved stitches or x-rays, where telemedicine was pretty much useless.
Three cheers for walk-in clinics.
Argiope
As an educator of new clinicians, I often see hesitancy among my students to use patient reports alone to make clinical decisions, even though about 90% of everything can be figured out this way if you ask the right questions. Of course, occasionally we need the other 10% (tests, imaging) to get to something definitive. I think many clinicians are trained to put their hands and stethoscopes on people, or see test results (objective findings) before they make any diagnostic calls–whether or not that information is actually useful. So I wonder whether the slow uptake in primary care has to do with clinician comfort zones? Mental health is almost 100% about patient report, so it’s an easier lift to provide this remotely.
EmbraceYourInnerCrone
For some things I would love if telemedicine would become more affordable and available. For instance with the now somewhat rare but very communicable childhood illnesses like strep, measles or chicken pox I would much prefer people be seen away from other patients. Also people who think they have influenza. On the other hand I would hope the worried cold sufferers who call and want an Rx for antibiotics would be refused. So sick of people thinking antibiotics are going to cure their cold ! I have known people whose GP writes prescriptions just cuz the person asks for them. Sigh.
Brachiator
Heard a commercial for a telemedicine app that would connect you to a doctor or physician assistant to diagnose minor conditions (UTIs?).
You could also get prescriptions.
beth
I work in mental health triage in a very large urban SF area county. We are ramping up telemental health psychiatry services due to a severe psychiatrist shortage verging on a public health crisis, particularly for pediatric psychiatry. Psychiatrists can write their own tickets these days, and it’s only getting worse. Just my personal experience.
beth
Also just want to add that mental health at a distance IS different from face-to-face in person services, as I know from now working on the phone versus decades of office visits. Also, psychiatrists prescribing certain meds, such as lithium, must get test results and such as well. I understand we are dealing with different problems from the medical side, but they are also life or death at times, too. And we need to deal with bad phone connections, emergencies, and reduced data input to work with.
Perhaps the new cohort will be trained in and more comfortable with telemedicine. It will be such a boon!
Gelfling 545
Doesn’t telemedicine involve internet contact? Internet access availability is a problem in rural areas.
Kay (not the front-pager)
Another use for urgent care clinics is for shift workers. The son who still lives with me works from a little noon to ~midnight and has a hard time working in appointments before work, where wait time can vary so much. Rather than take a chance on being late for work he uses an urgent care clinic that is open all night so he can go after work. Bonus, there are few other patients at that hour so he doesn’t need an appointment and rarely has to wait at all.
Tom D
In rural California (where I live) one cannot have an ER w/o an acute care hospital bed next door. IOW, no ER w/o a hospital. And hospitals don’t pencil in rural areas. The result is that emergency care is disappearing from the countryside.
There could be a 21st century solution which includes telemedicine, helicopters, and changes in the rules, but it would require attention and support from urban elites which I don’t often see here.
Mayken
I’m a severe asthmatic and telemedicine has saved my butt a couple of times. My current PCP and specialist are really great about getting people in same day/after hours or calling in scripts after just a conversation. But with previous docs that kind of help was rare to non-existent. So being able to get a doc online and say “I just need a round of steroids; here’s what I always get.” has been a lifesaver.
Kent
My wife is a primary care physician who does some telemedicine (and skype medicine).
I’m guessing, based on her experience, that telemedicine in general is much more common for follow-up care of existing patients rather than new care for patients for whom you do not already have a relationship. That would explain your third point where telemedicine is much more common in urban and well served areas.
For example, my wife simply will not see new patients over the phone. Not ever going to happen. She is going to want them to present themselves to the clinic where her nurse or assistant can first take all the baseline data (height, weight, vitals, etc.) and if it is a new patient she may order a panel of labs. She is also going to want to do a complete physcal exam in person. Down the road when she has a relationship with the patient and well documented notes in her electronic medical record she is going to be amenable to quick telemed calls to deal with simple issues…perhaps a reaction to a specific drug, or a follow up of some sort.
Rural and underserved areas are much more likely to have patents who do not have regular relationships with their primary care physician and so when they do need care of some sort it is much more likely that they will need to present themselves in person for at least the first visit.
Kent
@Gelfling 545: Often it is just a phone call, not skype or facetime.
Kent
Also not mentioned here is reimbursement rates. If/when primary care physicians earn the same reimbursement rate for a 15 minute telemed consult as they do for a 15 minute office visit I expect you will see it really take off.
wenchacha
My daughter recently Skyped with a psychiatrist. She lives in the Olympic Peninsula, and Seattle is about 2 hrs away. I am hoping this will be helpful for her.