Shinjita Das, MD, MPH, assistant professor of dermatology at Harvard Medical School and technology director in the department of dermatology at Massachusetts General Hospital, discusses the evolution of telehealth and its effect on patient-provider relationships.
Already a graph line on the rise through 2019, virtual doctor visits and other forms of telehealth surged ever higher during the pandemic. A recent analysis by McKinsey & Company shows that telehealth utilization in February 2021 had jumped to 38 times its pre-pandemic level. McKinsey estimates that the current $3 billion telehealth market could eventually grow to $250 billion if this trend continues,
Shinjita Das, MD, MPH, is a practicing dermatologist at Massachusetts General Hospital. As the inaugural technology director in the MGH Department of Dermatology, she leads initiatives and research to understand how technology can improve access to high-quality, efficient health care. Here, she answers our questions about the rapid evolution of telehealth and weighs in on how it will affect relationships between patients and primary care physicians.
Edited and condensed for clarity.
The most significant trend I’ve seen is that parallel health care systems are gaining momentum, propelled mainly by the pandemic. Traditionally, we think of health care delivered through brick-and-mortar doctor offices or hospital systems. But in recent years, large retailers such as CVS and Walmart have developed parallel health systems that consist of an emerging online or “digital-first” presence in conjunction with their brick-and-mortar infrastructure.
This shows us that the future of telehealth is not just an online-only experience but rather one that is more of a hybrid. A digital front door provides an entry point into the system, but these companies recognize there are times when people need to be seen in person for their care.
More traditional health care systems tend to be centralized in urban areas. Although there has been some expansion of community health centers, they may not have satellite sites in the community.
Walmart and other large retailers, which have a solid physical presence in the communities they serve, may have a better finger on the pulse of the health care needs of people who live in those areas. For example, 2022 figures showed 4,742 Walmart stores in the United States, which means that about 90% of Americans live within 10 miles of a Walmart. That market presence uniquely positions retailers to be serious contenders in the health care sector.
Currently, we are in the first generation of telehealth companies, which are mainly operating in the traditional fee-for-service arena. They provide a service and generate a fee paid for by the patient and insurance company. For example, a first-generation telehealth company may offer a subscription model for medications so that patients receive drugs for diabetes or high blood pressure regularly. But this business model alone cannot solve the dilemma of skyrocketing health care costs or improve health outcomes for patients.
In traditional health care systems, there has been an increasing shift away from the fee-for-service model toward population health management and value-based care, such as specific programs authorized by the Centers for Medicare and Medicaid Services. Under these models, health care systems receive a set amount of money for a pool of patients. They generate revenue by keeping people healthy. This means managing patients in the earlier phases of chronic diseases such as diabetes and finding ways to prevent them from developing long-term complications such as chronic kidney disease.
By creating value-based business models, health care systems have also taken on more risk. Increasingly, large health care systems are becoming de facto insurance companies, where they collect premiums from patients and then use that income to provide care and prevent patients from getting sick.
We’re starting to see the same trend emerge in second-generation telehealth companies. They are taking on the risk of managing population health and providing value-based care. For example, Firefly Health offers employers health plans that enroll patients in a digital-first primary care system. Second-generation telehealth companies are also hiring or contracting with doctors, nurses, health coaches, and others to bring that expertise in-house. The idea is to increase patients’ touchpoints with primary care and better coordinate care.
A study published in 2020 in Annals of Internal Medicine found a 47.7% decrease in primary care visits by insured patients for low-acuity conditions such as colds and a corresponding 46.9% increase in visits to urgent care clinics — almost a one-to-one replacement. What makes this interesting is that the researchers studied data from 2008 to 2016, a period well before the pandemic fueled greater use of telemedicine. This study shows that there’s been a trend over the last decade or so of less interaction between patients and primary care providers. The most significant decline in primary care visits was seen in three categories: young adults, those without chronic conditions, and those living in the lowest-income areas.
Telehealth may accelerate this trend. Rather than drive to a brick-and-mortar urgent care clinic, patients may opt to access care through telehealth. At a time when experts are predicting there will not be enough primary care practitioners to meet demand, telehealth could help reduce the burden. Patients who are young or healthy may find that telehealth adequately serves their needs. Patients who have multiple chronic conditions or require more care coordination may be better served by the more traditional primary care model.
However, we don’t know if low-income patients, or patients who primarily speak Spanish or another language, will be served well by telehealth. Patients must have sufficient financial and technological resources to access a virtual visit. We must be mindful of not worsening health care disparities through telehealth.
In the years ahead, I suspect we’ll see more strategic partnerships form between traditional health care systems and parallel health systems to serve patients better.
––Ann MacDonald
Continue the conversation by joining Shinjita Das at our upcoming Global Health Care Leaders program, or connect with us on Twitter @HMS_ExecEd, or with Shinjita Das on LinkedIn.