But wait a minute; didn’t the largest private insurer in the country just announce that it will begin paying for telemedicine services? Yes and no. UnitedHealthcare will pay for telemedicine encounters provided through a handful of telemedicine companies that are privately owned and venture capital backed corporations. UnitedHealthcare will be paying you squat for taking calls from your own patients, even if you do it on your spiffy iPhone 6, and even if you turn FaceTime on. However, if you sign up with Doctor On Demand, or American Well, to provide clinical advice on the iPhone to complete strangers, and fork over a portion of the proceeds to the corporation, UnitedHealthcare will pay you as well.
This may be the most wonderful incentive for physicians to toss any remaining continuity of care considerations out the window. After all, why should you spend all your days seeing one distraught patient after another, with or without “good” insurance, who may show up or may not, and who may pay you for your service or may not, when you can just sit in your office, and shoot the breeze with perfectly healthy people, each getting precisely 15 minutes face time, after they swipe their credit card to ensure that you get paid for every second of that time? Perhaps it would be wise for you to cut your regular panel down, get rid of those patients who trouble you the most, let the others see your assistant, and practice in-person medicine as a hobby, to keep your skills up and to add a little variety to your new electronic career.
In its announcement UnitedHealthcare cites the mythical 45,000 physician shortage, particularly in rural areas, as the impetus for providing telemedicine services to its members. Having board certified and experienced physicians cater to a constant stream of colds, sinus infections, allergies and tummy aches, all of which are recommended to be delegated to non-physicians working at the “top of their license” in traditional practice, is somehow supposed to alleviate this shortage. Providing a means for urban and out of state physicians to compete with country docs, for credit-card carrying worried-well, is envisioned to improve the disparities in access to quality medical care in rural America.
Why then is UnitedHealthcare (and other private insurers as well), encouraging further fragmentation of primary care and massive waste of physician time? “The cost of a video-based virtual visit is less than $50 and provides significant savings when compared to costs for similar minor medical needs treated at a doctor’s office ($80), urgent care facility ($160) or emergency room ($650)”. And that’s all the myopic reasoning we need. Getting $50 for an easy 15 minutes (or less) session and subtracting the corporate share, a physician may end up with approximately $140 per hour and no overhead. It’s pretty good if you are moonlighting, but less so if you sit in your fully staffed office fiddling with your iPhone in the middle of the day. If you do this type of work full time, which is pretty much what people do in retail clinics, or call-a-nurse type of services, do you still consider yourself a doctor? Just wondering……
That may soon be a moot question though, because the “promise of telemedicine” is being fulfilled as we speak. First Opinion, a venture-capital backed company, is taking telemedicine to where no doctor has gone before. First Opinion is bringing back the “intimacy” of “meaningful relationships” to health care by deploying an offshore cadre of exclusively female “certified doctors” who will respond to your text messages as often as you wish, day or night, free of charge. You must solemnly swear that “you will not attempt to learn the identities and/or locations of the “Drs.””, who may or may not be “who they claim to be”, and of course First Opinion is taking absolutely no responsibility for “the quality, reliability, timing, legality, integrity, authenticity, accuracy, appropriateness” of its strictly non-medical telemedicine.
If this particular flavor of telesnakeoil sounds like a petty aberration that will most certainly be shut down, you need to know that this particular business model is the spitting image of the decades old disruptive innovations that swept other science, technology, engineering and math (STEM) fields. It starts with the fabrication and propagation of stories about shortages of qualified workers and how high wages are bankrupting the industry. It then proceeds to the offshoring of and the importation of temporary foreign workers for “low skilled” functions that Americans supposedly have no interest in performing (think primary care). Before you know it, the President is bemoaning the STEM shortages in the State of the Union, and global corporations are forcing the passage of legislation to encourage a steady supply of cheap STEM labor. In the meantime, STEM wages are stagnating and most STEM graduates are forced to look for jobs in other fields.
The S in STEM stands for science. Physicians are STEM workers. And the billionaire funded Partnership for a New American Economy, which is aggressively campaigning for increased temporary worker visas, has physicians and nurses squarely in its crosshairs. Sending medical work overseas and importing cheap physician labor from developed countries is not going to be as easy as it was in the tech industry, not because our doctors are the best of the best (our engineers used to be the best too – quality is not the point here), but because of existing regulatory hurdles tying the practice of medicine to a geographical area which is smaller than planet Earth. Once State by State medical licensure requirements are removed with active support from shortsighted physician organizations, the (oh, so expensive) residency requirement will be next on the chopping block, and the transformation will be complete.
In a last ditch effort to stem the tide of physician nullification, the Texas Medical Board (TMB) is trying to put a modest stake in the ground by ruling that physicians can only provide telemedicine services to patients with whom they have a preexisting in-person relationship, or if another clinician is present at the patient’s location. This rule permits basically all modalities of useful telemedicine services, except the “one-and-done” type of remote encounter, where a minor ailment is diagnosed based on hearsay and, most importantly, antibiotics are diligently prescribed. I did not see any massive support for the TMB from physician organizations. Instead the TMB was slapped with a lawsuit from Teladoc, a telemedicine service provider, getting ready to go public and arguing that by enforcing a standard of care, the medical board is interfering with Teladoc’s God-given right to make lots of money.
Telemedicine, you see, is the greatest innovation since sliced bread, and it is going to do for America’s health exactly what its predecessor did. You don’t need to be a “futurist” to see where this is going. The TMB will most likely lose its case in courts stacked with corporate lackeys. Next, the unregulated interstate commerce in telemedicine will further accelerate the exodus of physicians (and hospitals) from rural and working-class areas, which is a good thing for telemedicine vendors. Finally, the best paid middle class profession will be “globalized” to places where “doctors” work for less than American minimum wages, and we will all be conditioned to crave and consume deadly amounts of convenient and nearly free iPhone medicine.
You may be tempted to blame the public for its quest for cheapness and convenience, or for its inability to value a relationship with a trusted physician. You may be increasingly frustrated by the starstruck media and its unquestioning worship of all things originating from Silicon Valley, and you may be disheartened by corrupt government acting on behalf of billionaire thugs to swindle the populace. But where are our doctors? Not the offshore avatars, and not the ones submitting themselves to $40 peepshow sessions, but the overwhelming majority of American physicians, still anchored in their communities and still practicing ethical medicine, one patient at a time. Where are you guys?