Below, we feature a post by a clinician who confirms our concerns. He had advocated telemedicine in the pre-Covid era. He warns that telemedicine is creating cookie-cutter by design “doc in a box” practices, for instance restricting participating MDs in the tests they can run.
It had not occurred to me that the telemedicine services provided to MDs would be anything more than established MDs consulting with patients by phone, as they routinely did in Australia in the early 2000s, and/or getting a secure videoconference line. Earlier this year, in Alabama, my mother’s crusty MD reluctantly did her annual exam by phone. But my regular doctor in New York insisted on video (I needed an office visit for her to consider giving me a new scrip), claiming it was necessary to be “HIPPA compliant.” That made me wonder if she thought she was required to retain a recording. I didn’t find that acceptable (I also generally hate videoconferencing with the passion of a thousand suns) and flew to New York instead (yes, I am insanely protective of my medical privacy).1 This discussion of the tech of telemedicine makes me think I am less nuts than I did before.
This post doesn’t acknowledge another pet peeve: in Australia, telemedicine in the form of phone consults for established patients was well established. It was also understood to be a supplement to office visits, not a substitute for them, and priced accordingly.
Due to Covid-19, CMS mandated payment parity for telemedicine visits. This is unfortunate since for some, perhaps arguably many types of concerns, a telemedicine session simply cannot allow for as much diagnosis as a live visit. The doctor cannot listen to your lungs and heart, stick a light in your ear, see your skin color accurately, poke your belly if it needs poking, or examine body parts that are not behaving normally. And if the doctor provides a treatment, it would seem probable that at least for some patients, the placebo effect would be reduced.
In other words, a practice that ought to be a boon looks set to become a vehicle for crapification. And the US medical system is pretty crappy to begin with.
By Cetona. Originally published at Health Care Renewal
1. Introduction. This post might just as easily be entitled “tales from the crypt,” so far down the netherworld chute have American public health and medical workers been plunged. Nowadays whenever I speak to fellow physicians and tell them I’ve moved on from my own front line patient care, we exchange these utterances: they say “congratulations, I’m envious” and I say “my condolences.” But the topic for today is more focal: telemedicine in the Age of Coronavirus.
Telemedicine, or “telemed,” doesn’t quite fit neatly into my ongoing series on why my dander’s up. So for now let’s set it aside and come back another time. It turns out that telemed—remote diagnosis and treatment using telecoms—is, like so many other innovations in health care, a two-edged sword. Let’s look at it and see if we can come up with provisional answers to what, exactly, it means, beyond fear of face-to-face, to see its use soaring these days.
I’ve observed telemedicine now in a number of settings—lots of testimonials from colleagues, family, friends, and in just one instance myself as patient. Most of this is quite recent, for reasons we’ll get to. I’ve never practiced it, never had time on my schedule to Zoom into some patient’s bedroom. That’s just an artifact of the timing. But I used to teach about it. And now it’s arrived like gangbusters after languishing for decades in the ever-hopeful hearts of long standing organizations (here, here) devoted in part or in full to digital medicine.
The “why” for this onrush of telemedicine exposure is an easy one. In the Before Times, we had reimbursement problems that impeded it. All the other barriers, by, say 2010, were secondary. All our clocks now have a thick black line between BC and AD. Before Coronavirus versus After Donald.
Back in the BC, we can’t get it paid for. Now, in the almost-AD: HHS rushes out new emergency regs, enabling telemed. With the pandemic, the new regs arrived just when providers, deprived of adequate PPE and in some cases a big chunk of salary, really needed the option. Whether they actually approved of it or not, different story. Necessity is the mother. All the rest is dross.
The above remarks set the stage. We just need to remind ourselves in passing: there’s just not much scientific evidence for this technology’s safety or efficacy. Rather, like so much else in digital medicine, telemed is probably here to stay because of one or another regulatory or epidemiologic crisis. Contrariwise, it’s not an evidence-based imperative, at least not with respect to clinical results. For providers, of course, it may well mean survival, a different story.
So until we get more convincing science, here, for this blog’s intrepid readers, are some narrative bits and bites to chew on: telemedicine, the good, the bad, and the ugly.
by Yves Smith, Cetona, Naked Capitalism | Read more:
[ed. This tracks with my experience these days, not just with telemedicine, but with hospitals in general (and doc-in-a-box staff that appear to want as little interaction with patients as possible). I get the sense that I'm just a billable code, their main priority being moving patients through the system).]
