In a recent podcast about the future of telehealth, Lyle Berkowitz, MD, a technology consultant, entrepreneur, and professor at Northwestern University’s Feinberg School of Medicine, confidently predicted that, because of telehealth and clinical automation, “In 10-20 years, we won’t need primary care physicians [for routine care]. The remaining PCPs will specialize in caring for complicated patients. Other than that, if people need care, they’ll go to NPs or PAs or receive automated care with the help of AI.”
Berkowitz isn’t the first to make this kind of prediction. Back in 2013, when mobile health was just starting to take hold, a trio of experts from the Scripps Translational Science Institute—Eric Topol, MD, Steven R. Steinhubl, MD, and Evan D. Muse, MD—wrote a JAMA Commentary arguing that, because of mHealth, physicians would eventually see patients far less often for minor acute problems and follow-up visits than they did then.
Many acute conditions diagnosed and treated in ambulatory care offices, they argued, could be addressed through novel technologies. For example, otitis media might be diagnosed using a smartphone-based otoscope, and urinary tract infections might be assessed using at-home urinalysis. Remote monitoring with digital blood pressure cuffs could be used to improve blood pressure control, so that patients would only have to visit their physicians occasionally.
It’s the telehealth market reality check you’ve been waiting for! “Rogue” digital health consultant Dr. Lyle Berkowitz unpacks the numbers and the market potential for virtual care from the unique vantage point of a primary-care-physician-turned-health-tech-entrepreneur with nothing to lose. Having been 1) a clinician, 2) the Director of Innovation at Northwestern Medicine, 3) the founder of a health tech startup (Health Finch) that successfully exited to Health Catalyst, and 4) the former Chief Medical Officer at one of telemedicine’s biggest players, MDLive, few can boast such a wide-reaching, deep understanding of the inner workings of both the innovation and incumbent sides of the virtual care market — AND have a willingness to talk about it all with complete candor!
This is an analyst’s perspective on the telehealth market — with a twist of insider expertise — so expect to hear some good rationale behind predictions about how much care will remain virtual once hospitals and doctor’s offices return to normal, how “real” health system enthusiasm is for building out telehealth capacity to execute on the “digital front door” idea, and whether or not all these well-funded telehealth startups will have what it takes to win market share from traditional care providers.
BONUS on Primary Care: Is this the area of medicine that’s going to be the “battleground” where digital health and virtual care companies will be going head-to-head with incumbents for market share? Lyle says 50-plus percent of primary care “can and should be automated, delegated, virtualized, etc.” and boldly predicts that in 10-20 years we won’t even have primary care physicians anymore. Tune in to find out why starting at the 8:00 minute mark, where we shout out Crossover Health, Oak Street Health, Iora Health, and more.
Telehealth die-hards, don’t think for a second I’d miss this chance to also get some input on Teladoc-Livongo, Amwell, Doctor On Demand, SOC Telemed, the impending IPOs there, digital first health plans, virtual primary care, health systems (who Lyle hopes “don’t shoot themselves in the foot” with their opportunity to jump into the space) and, ultimately, who’s really going to ”WIN” in virtual care moving forward. For this, jump in at 17:00 minutes and hold on!
(This is the fourth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
Many other countries’ healthcare systems outperform ours for one simple reason: They place a much greater emphasis on primary care, which occupies the central place in their systems. “The evidence is that where you have more primary care physicians, where you coordinate care, and where you pay to keep people healthy, you get better outcomes at lower cost,” says David Nash, MD, founding dean of the College of Population Health, part of Thomas Jefferson University in Philadelphia.
The evidence that Nash mentions includes studies by Barbara Starfield and her colleagues at Johns Hopkins University. In a 2005 Health Affairs paper, they showed that a higher ratio of primary care physicians to the population is associated with a lower mortality rate from all causes and from heart disease and cancer; in contrast, having more specialists in a particular area does not decrease the overall mortality rate or deaths from cancer and heart disease.
Another study of Medicare data found that states where a higher percentage of physicians were PCPs had higher quality care and lower cost per beneficiary. This factor alone accounted for nearly half of the variation in Medicare spending from one state to another. A separate study found that in the areas of the country that had the most primary care providers, the average Medicare cost per beneficiary was a third lower than in areas with the least PCPs.
One reason for this is that primary care doctors provide comprehensive, continuous care, including preventive and routine chronic care. Chronic illnesses drive 90% of health costs, and some studies show that intensive primary care can reduce ER visits and hospital admissions and improve the health of chronically ill people.
Meaningful Use was a vision for EMRs that in many ways turned out to be a joke. Consider my list of Meaningful U’s for medical providers instead.
When electronic medical records became mandatory, Federal monies were showered over the companies that make them by way of inexperienced, ill-prepared practices rushing to pick their system before the looming deadline for the subsidies.
The Fed tried to impose some minimum standards for what EMRs should be able to do and for what practices needed to use them for.
The collection of requirements was called Meaningful Use, and by many of us nicknamed “Meaningless Use”. Well-meaning bureaucrats with little understanding of medical practice wildly overestimated what software vendors, many of them startups, could deliver to such a well established sector as healthcare.
For example, the Fed thought these startups could produce or incorporate high quality patient information that we could generate via the EMR, when we have all built our own repositories over many years of practice from Harvard, the Mayo Clinic and the like or purchased expensive subscriptions like Uptodate for. As I have described before, I would print the hokey EMR handouts for the Meaningful Use credit and throw them in the trash and give my patients the real stuff from Uptodate, for example.
I’d like to introduce an alternative set of standards, borrowing the hackneyed phrase, with a twist. MEANINGFUL U’S for medical providers:
He cancelled his followup appointment because he was feeling fine. He didn’t see the point in wasting a Saturday to come to my clinic when he had lawns to mow and chores to do.
Less than two weeks before that he was sitting on the exam table in my office, again and again nodding off, waking up surprised every time his wife prodded him. The stack of printouts from the emergency room illustrated all the normal testing they had done.
He had experienced a brief episode of numbness in the left side of his face and felt tired with just a slight headache. When I saw him the headache was a bit more severe in the back of his head and down the right side of his neck. But his neck wasn’t stiff.
His blood sugar was 87, normal for most people, but this man had a history of diabetes although his blood sugars had steadily improved over the past year. I told him to stop all his diabetic medications although I don’t think he took notice. His wife said she would make sure he stopped them.
Today on Health in 2 Point 00, it’s the 4th shoe! On Episode 135, we’ve got Amazon’s entry into primary care through its pilot program with Crossover Health, UnitedHealth Group launching Level2, their own digital health diabetes prevention program, Health Catalyst acquiring healthfinch, Truepill raising $25 million and then investing in Ahead, a company which matches psychiatrists to patients. —Matthew Holt
The Smithsonian National Museum of Natural History has reported its biggest number of visitors in more than 2 ½ years. There’s a string of new Broadway musicals that are well-attended every night. It’s safe to shop in malls, eat out in restaurants and go to movie theaters again.
Of course, this has all been made possible by an effective vaccine against COVID-19 that was widely administered in the fall of 2021. Vaccinated citizens of the world are now confident that it’s safe to go out in public, albeit with appropriate precautions.
However, U.S. residents who have health problems are facing a new challenge. Five years ago, in 2017, the median wait time of new patients for doctor appointments was six days. In 2022, the wait time is six months or more.
The reason for this is no mystery. While life has started to return to what we think of as the new normal, the U.S. healthcare system has taken an enormous financial hit, and primary care practices have been especially affected. Many primary care physicians have closed their practices and have retired or gone on to other careers. Consequently, the shortage of primary care has been exacerbated, and access to doctors has plummeted. Urgent care centers, retail clinics and telehealth have not filled this gap.
Because of the long waiting times for primary care appointments, many more people now seek care in emergency departments (EDs). The waiting rooms of these EDs are overcrowded with people who have all types of complaints, including chronic and routine problems as well as emergencies. And this is not just a common sight in inner-city areas, as it once was; it’s now the same pretty much everywhere.
After my posts on telemedicine were published recently, (this one on Manly Wellness before the pandemic and this one after it erupted, on A Country Doctor Writes, then reblogged on The Health Care Blog, KevinMD and many others), I have been asked about my views on telemedicine’s role in the future of primary care.
Things have changed quickly, and a bit chaotically, and there is a lot of experimentation happening right now in practices I work or speak with.
Before thinking about telemedicine in Primary Care, we need to agree on some sort of definition of primary care, because there are so many functions and services we lump together under that term.
Many people think of primary care mostly as treating minor, episodic illnesses like colds, rashes, minor sprains and the like. This is an area that has attracted a lot of interest because it is easy money for the providers, since the visits tend to be quick and straightforward and such televisits are also attractive for the insurance companies if they can keep insured patients out of the emergency room. With the technical limitations of video quality and objective data such as heart rate and rhythm, I think this is an absolute growth area for telemedicine. However, with all the other forms but mostly here, fragmentation of care could become a complicated problem. To put it bluntly, if we still expect a medical professional or a health care organization to keep an eye on reports from various sources, such as hospital specialists, walk-in clinics or independent telemedicine providers, they are going to want to get paid for it.
Healthcare today, in the broadest sense, is not a benevolent giant that wraps its powerful arms around the sick and vulnerable. It is a world of opposing forces such as Government public health ambitions and more or less unfettered market ambitions by hospitals and downright profiteering by some of the middlemen who stand between doctors and patients, such as insurers, Pharmacy Benefits Managers, EMR vendors and other technology companies.
Within healthcare there is also a growing, more or less money-focused sector of paramedicine, promoting “alternative” belief systems, some of which may be right on and showing the future direction for us all and some of which are pure quackery.
I stand by my conviction that physicians must embrace the role of guide for their patients. If we see ourselves only as instruments or tools in the service of the Government, the insurance companies or our healthcare organizations, patients are likely to mistrust our motives when we make diagnoses or recommend treatments.
Today, primary care is considered the bee’s knees of value-based care delivery. Instead of being viewed as the punter of the football team, the primary care physician (PCP) has become the quarterback of the patient’s care team, calling plays for both clinical and social services. The entire concept of the accountable care organization (ACO) or patient-centered medical home (PCMH) crumbles without financially- and clinically-aligned PCPs. This sea change has resulted in rapid employment or alignment to health systems, as well as a surge in venture capital being invested into the primary care space.
Before we get too far in the weeds, let’s first begin with the definition of primary care. The American Academy of Family Physicians (AAFP) defines a primary care physician as a specialist typically trained in Family Medicine, Internal Medicine, or Pediatrics. Some women do use their OB/GYN as their PCP, but these specialists are not traditionally considered PCPs. Now if you’ve gone to your local PCP and noticed that your care provider is not wearing a white coat with the “MD” or “DO” credentials, you are either receiving treatment from a hipster physician, nurse practitioner (NP), or physician assistant (PA). Two of the three professionals are trained in family medicine and can provide primary care services under the responsibility of an associated PCP. At least one of the three has a beard.
The crazy thing is, despite the industries heightened focus on the importance of PCPs, we’re still expecting a shortage of primary care providers. In April 2019, the Association of American Medical Colleges (AAMC) released a report estimating a shortage of between 21,100 and 55,200 PCPs by 2032. Given we just passed 2020, this not that far off. The primary reason for the shortage is the growing and aging population. Thanks mom and dad. Digging into the numbers will really knock your socks off, with the U.S. Census estimating that individuals over the age of 65 will increase 48% over that same time period. Like a double-edged sword, the issue is not just on the patient demand side though. One-third of all currently active doctors will be older than 65 in the next decade and could begin to retire. Many of these individuals are independent PCPs who have resisted employment by large health systems.