Common wisdom tells us that the more people are insured, the more preventative care happens, the less complex and expensive illness we treat, and so the less we have to spend on healthcare overall.

This logic was a large part of the rationale for the Affordable Care Act. As President Obama said in his 2009 address to Congress, “There’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.”

Interestingly, that's all wrong.

As the New York Times recently reported, "There’s strong evidence from a variety of sources that people who have health insurance spend more on medical care than people who don’t. It also turns out that almost all preventive health care costs more than it saves." Jonathan Gruver, an MIT Economist, goes on to explain: “It’s a nice thing to think, and it seems like it should be true, but I don’t know of any evidence that preventive care actually saves money,”

Long story short, good preventative care saves money for individual patients. It doesn't, however, save money overall since it costs more to help everyone avoid the disease than it does to treat the few people who would have ended up getting it. Plus, as we've explored in other posts, the newly insured also tend to place a burden on providers and hospital systems, since these patients tend to be sicker than average.

So if treating complex illness is expensive, and preventing illness is expensive, is there any way that we can be active about saving money as providers and administrators?

Yes. I think there are a few things to keep in mind, even as it can seem discouraging when the "right" thing (preventative care) doesn't ultimately save costs to the overall system.

First, medical providers often know what the best course of treatment is for an individual patient (even with a healthy consideration of costs), even if the population-level design can be murkier. Plus, as the New York Times reports, cost savings do happen when providers are able to make sure that work isn't duplicated or wasted. For instance, medical collaboration can keep patients from falling between the cracks during transitions. And telemedicine can decrease overall costs in a hospital system, decrease length of stay, and improve readmissions. Dr. Brent C. James affirms that this type of measure can decrease costs, calling it the “do it right the first time" approach.

 

To explore how telemedicine decreases costs and improves care, click here: 

 

Many states are wisely removing barriers to telemedicine. You can see in the American Telemedicine Association's ranking of states' friendliness to telemedicine technologies that places like Virginia and New Mexico are making it easier for reimbursement and care to happen using telehealth.

Of course, some states (and some organizations) are battling these changes. For instance, the Texas state medical board recently challenged the use of telemedicine in the state (it appears the challenge may have been overturned.) All of which seems a little misguided when you hear stories of just how impactful telemedicine programs can be. Stories and data abound about their impact, excellent care, and cost savings.

Among the many (just as one example), we recently came across a great study of a pediatric telemedicine impact and savings. The University of California Davis Children's Hospital did research on the costs of implementing and maintaining a telemedicine program and compared them to 8 rural emergency medicine departments over the course of 6 years.

The researchers found that the telemedicine program improved quality, safety and patient satisfaction. In terms of costs, they found a $1.96 return on investment (ROI) for each dollar spent on telemedicine.

So it's not tough for us to see that telemedicine is worth it, especially when it's implemented in thoughtful ways. And we laud all of those pioneers who are "making the path by walking" as the data emerges to support their work.

 

 

 

 

 

 

Photo used under Creative Commons rights from lowercolumbiacollege on Flickr

A recent New York Times article tells the story of Jerome Pate, a homeless man who visited the Emergency Room 17 times in 4 months last year. He would go if he was sick. And he would go if he was cold, or drunk, or hungry, or suicidal. In other words, he had a lot of visits, for minor or nonexistent medical problems, with a serious root cause (in this case, his homelessness). Mr. Pate was a super utilizer. 

“We had this forehead-smacking realization that poverty has all of these expensive consequences in health care,” said Ross Owen, a county health official who helps run the experiment here. “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.” This type of pattern would have actually been a cost center in the old medical system. When you're paid by the visit, many visits for small or nonexistent problems actually work in favor of the hospital in terms of profit.

In an age of penalties for readmissions, and pay-for-performance being the rule of the day, this is not a strategy that works.

More than 11 million Americans have joined the Medicaid rolls since the major provisions of the Affordable Care Act went into effect. For those patients, as well as for Accountable Care Organizations and managed care hospital systems, super utilizers can be a major source of costs -- as well as care that doesn't really meet the patient's needs.Some people have expensive problems that are only solved by many hours of a single specialist. But some of the largest shares of spending are actually from the super utilizers who are racking up costs with very simple problems.

Hospitals and providers who use iClickCare have been finding that the needs of super utilizers can be best met with the support of telemedicine. When providers collaborate across the spectrum of care, it is much easier to deal with patients who have nonmedical issues exacerbating or causing their primary compliant. It allows providers to communicate on their own time, across buildings, and spanning visits.

Here are 3 ways telemedicine and medical collaboration can help you care for super utilizers and make sure costs are contained:

• Stop people from falling between the cracks. With Mr. Pate, for instance, the hospital's procedures and systems made it so that each time he came in, the ER team assessed and/or treated him for the medical concern he presented with. Even if the providers in the ER were aware of the nonmedical issues he was facing, they had no good way to connect him to the services he needed -- services that may have prevented him from circling back to the ER the very next week. With a medical collaboration platform like iClickCare, an ER doc could leave a question or consult for a health outreach or social service worker at 3am and that other provider could connect with the patient or the original doctor the next day.
• Create a broad treatment team. Because medical collaboration lets you create a treatment team across the spectrum of care, the components of a patient's problems that are less directly "medical" can be cared for. A collaboration in iClickCare, for instance, can include teachers, health outreach workers, social workers, the ER doctor, a specialist, and a primary care doctor. All sharing their thoughts and questions on their own time, in a single place.
• Resolve the root problem the first time. In Mr. Pate's case, he was 17 visits in and his root problem -- his homelessness -- still hadn't been addressed. It is better care (and more cost effective) to buy a person a pair of winter boots than to amputate a diabetic's foot. And a telemedicine platform can allow providers to get to the root of the problem through collaboration and continuation of care -- without allowing things to get bad, painful, and expensive. 

 

For our complete Quick Guide on telemedicine, click here: 

 

"It is only with the heart that one can see rightly; what is essential is invisible to the eye."
Antoine de Saint-Exupery

As a small business trying to take on the medical system, we certainly gravitate towards things that help us be more productive. When we find a more efficient way to do something, we usually seize it.

The medical system seems to have the same impulse. If three minutes can get stripped off a visit, those three minutes get eliminated. If a step can be removed from a process, administrators are thrilled to advocate that providers do so.

Sometimes, these "efficiencies" in medicine lead to significant losses and unintended consequences.

For example, one thing we've noticed being eliminated from medicine -- because it's not efficient -- is everyday collaboration, information sharing, and human interaction. A highlight of my schedule as a surgeon has always been sitting in the doctors' lounge in the spare 10 minutes before an operation. I'd chat with other doctors who also had a free minute about new medical findings, our kids' sports, a shared patient, or a treatment conundrum. Those simple interactions would be satisfying in all kinds of ways, but with very few tangible, "efficient" outcomes. Over the course of a week, though, I always gained powerful insights, identified care opportunities, and collaborated in ways that saved time and improved quality of care.

Recently, we came across a couple of articles that show how the efficient, streamlined approach can actually strip out huge positives in other contexts. For instance:

• Everything from asthma to obesity is affected by the microbial balance in our gut. As this informal article describes, some research is now showing that it is integrated, indirect consequences or combinations of healthy habits that seem to improve our intestines' microbial makeup and protect us from disease. For instance, the negative effects of a McDonald's breakfast on inflammation can be nullified by drinking a glass of orange juice with the meal. Researchers haven't yet been able to strip out the "active" component of the orange juice in the dynamic system and are concluding that it is actually the combination of things like flavinoids, antioxidants, vitamins and soluble fiber that create the effect. 
• It turns out that "Ground-up artemisia plants, from which the anti-malaria drug artemisinin is derived, appear to work much better than the refined drug does by itself, according to research at the University of Massachusetts," reports the New York Times. Why? The plant goes beyond just the active ingredient that we extract to create the anti-malaria drug. Much like with the orange juice (or the doctors' lounge), it is a combination of multiple factors that create the positive effects -- and a shortcut won't get you all the way there.

That's why, when we are asked for advice on telemedicine and medical collaboration, we always suggest using common sense and not necessarily doing the most efficient, stripped down, basic thing. For instance, secure text messaging services can be effective in some situations, but often lose the richness of real interactions. Sometimes, a face to face conversation is still the best way to determine a course of treatment. And when that's not possible, we believe that a telemedicine solution that incorporates informal discussion, video, photos, and perspectives from multiple providers (like iClickCare) is the way to go.

In the same way that the plants are more effective than the malaria drug itself, we advocate for "leaving in" some of the still-inexplicable positives that come from doing the traditional thing that works. Have the conversation, even if it's not 100% obvious what came of it. Use the richer store-and-forward solution. Do what works, even if we don't yet understand all the reasons why it works so well.

To learn more about why Hybrid Store and Forward Telemedicine is often the best option, get our free guide:

Often, telemedicine is seen as the domain of the advanced, the technologically savvy, and the well-to-do. People assume that something so "sophisticated" as e-health, remote visits, or telemedicine-supported medical collaboration couldn't work for their clinic, their context, or their patients. 

In fact, we've had the experience that, as with many disruptive technologies, telemedicine has first benefitted the under-resourced, the underserved, and the marginalized. Our journey with telemedicine started in the late 90s, at one of the poorest elementary schools in our county. Originally, we were just looking for a simple way for kids -- whose parents couldn't miss hours of work and still pay the bills -- to get specialized medical care. We ended up using early digital cameras and distance learning lines to piece together a telemedicine program, in what would eventually become an early version of iClickCare.

All of which is to say that in our experience, telemedicine can be a simple thing. It can be a human thing. And it can certainly work in under-resourced environments.

So when we saw a recent article over at Fierce Health IT about how prisons are increasingly adopting telemedicine, it made perfect sense to us. Prisons, of course, have different parameters than most care settings. And they may even have different goals in the care of their patients. While they manage their lives, in a sense they are also providing managed care. But we all share common challenges in providing good, safe, efficient care for our patients -- and telemedicine is a great tool for many of us.

So here are 3 reasons that prisons use telemedicine and that you might want to consider it, too:

• Telemedicine removes downsides of travel. For prisoners, the ride to the hospital or to a specialist can be an expensive endeavor and present risk of escape. And while most patients don't have the escape-avoidance challenge, travel to faraway specialists and providers can be costly, mean missed work and school, and be highly disruptive of the healing process.
• Telemedicine saves money. We've repeatedly seen high ROIs (both financially and in terms of quality of care) for organizations and providers that adopt telemedicine practices. As Dr. Michael Moore experienced: "During a 3 month period, 70 patients were treated solely using iClickCare with an overall healing rate of 93% and an estimated savings of $24,000 in transportation costs alone." The prisons are seeing the same impacts, which is why these programs are increasingly common across the country.
• Telemedicine can make both the patient's and the provider's lives easier. Beyond just cost savings, the trauma and "run around" of caring for a chronic condition -- managing schedules, managed care, coordinating appointments, waiting for consults, and sharing information -- can be exhausting for both patient and provider. Telemedicine, especially a hybrid store-and-forward model that doesn't demand everyone be available at once, can make everyone's lives easier.

 

If you're wondering if Hybrid Store-and-Forward Telemedicine is right for you, get our free Quick Guide:

 

 

 

Image courtesy of franekn on Flickr, used under Creative Commons rights. 

 

 

These days, medical providers have to tend to a lot of moving pieces, just to ensure they're keeping pace with the expectations of their institution, insurance companies, and the government -- not to mention providing good care. For instance, these are just a few of the things we providers are held to: 

• Length of stay in the hospital
• Readmissions
• ROI
• Cost effectiveness of the care
• The "triple aim:" patient experience of care, health of populations, and per-capita cost.

In all of these metrics and objectives, there is someone conspicuously absent: the medical provider. 

Whether you are a nurse, WOCN, specialist, or general physician, it would seem from this common list of priorities that you are, well, not a priority. A great recent article on Fierce Practice Management challenged this omission. The article cites a recent study by Bodenheimer, MD and Sinsky, MD that suggests healthcare provider burnout is severe, widespread, and significantly influences the quality of medical care: "The industry can't achieve the Triple Aim's core ideals--providing better care, improving population health, and lowering costs--without first improving the work life of healthcare providers."

Of course, healthcare provider burnout affects one of every two providers, and we've written extensively about how medical collaboration and telemedicine can help to ameliorate it. But this study is one of the the first times that we've heard incisive commentary on why improving burnout for providers is crucial to our overall goals for healthcare. In other words, how happy and healthy medical providers are is crucial to whether their patients will get good care. As the study authors confirm:

"Healthcare is a relationship between those who provide care and those who seek care, a relationship that can only thrive if it is symbiotic, benefiting both parties."

We've always known that the patient can't thrive when the provider is suffering and that the provider can't thrive unless her patients are healthy and successful. Now, we're starting to see the evidence for it. 

 

Image courtesy of schnappischnap on Flickr, used under Creative Commons rights.

When hospitals and providers decide to use telemedicine as a tool, ROI and cost effectiveness is always a factor. Telemedicine makes it more cost-effective to see our patients and provide a high level of care, so of course that is part of the equation. 

But a recent New York Times article got us thinking. The author does specifically advocate for a thoughtful usage of cost effectiveness data in care decisions. But also he acknowledges that the approach can go very wrong. For instance, he tells the story of an Oregon woman who was denied a $4,000 per month lung cancer treatment by Medicaid because it wasn't deemed cost effective... and then was told that Medicaid would, in fact, cover drugs for physician-assisted suicide since she now had few other options.

Situations like this make many medical providers -- and patients -- want to run for the hills and declare "cost effectiveness" a dirty word.

Despite the US medical system being among the most expensive in the world, we do provide some of the best and most innovative medical care in the world. We've innovated approaches to care that resonate across the planet. And we've all heard horror stories of the illogic and bad care that can happen when providers are treated like factory workers, prioritizing efficiency and cost savings above all else. 

So what is the answer? Should cost effectiveness be considered in care decisions and policy?

Perhaps like everything else, it is an issue of balance. It is clearly unsustainable to ignore cost effectiveness altogether -- and costs in one area of the medical system will eventually affect others. On the other hand, blanket policies that eliminate classes of care are bad medicine and sometimes inhumane. So, as so often is the answer, the providers must use their judgement. Even when it comes to costs, medicine is both an art and a science.

 

 

 

 

 

 

 

 

Anyone who has recently been sick knows that the cost of healthcare is high. In fact, healthcare spending in the United States is twice as much as it is in any other developed countries. And, as medical providers, we know that we're in no way benefitting from these high costs to consumers and the system. In fact, as overall costs rise, we as providers are simply increasingly squeezed to do more with less, faster.

So it is puzzling (and maybe hopeful) to read reports that health spending is actually slowing down significantly. The New York Times has been reporting that health spending in 2013 grew at the lowest rate since government officials started tracking it — back in 1960. The slowdown in health spending growth began over ten years ago, and has been especially pronounced in the last four years.

Some studies attribute this decrease in health spending to the overall recession, but many analysts say that it's not just about the economy. In fact, the New York Times, identifies several key components of this decrease, all of which are elements we see as strongly supported by medical collaboration and the use of telemedicine:

• Decrease in hospital spending. It seems that instead of going straight to the hospital, people may be getting care in their doctor's office or other lower-cost settings. We've seen telemedicine support this kind of patient behavior, as providers can get consults from specialists or other providers without the patient having to make additional appointments.
• Reduction in readmissions. Readmissions have long been singled out as a major opportunity for cost savings. And as we've looked at in other posts, medical collaboration (especially as supported by telemedicine) can be fundamental to managing readmissions.
• Drop in errors. The final potential cause for the decrease in medical spending is a decrease in errors. Over and over again, we've seen errors decrease when providers can support each other in making good decisions, doing follow up care, and getting the help they need.

Of course, none of these reasons are proven or conclusive. But we do breathe a small sigh of relief that the efforts of so many in changing medicine may be starting to show results.

See how telemedicine can affect your ROI by giving it a try today: 

 

Image courtesy of chazoid on Flickr, used under Creative Commons rights.

 

My daughter works in a busy (hectic might be a better word) public-health clinic in New York State. It's a challenging patient base -- one with complex diseases and more complex life contexts for each patient. Even with those tricky conditions, these providers have had such extraordinary results that their practices are used as a model across the state.

That said, even her clinic struggles with no-shows. Providers will squeeze patients into an already overfull schedule, only to have that individual no-show the next day. Or a patient will be missing at their appointment time, but ask to be seen several hours later. It's difficult, but it's not surprising: the New York Times cites a no-show rate of up to 55% for most providers.

Non-compliance, of which patients not showing up for appointments, tests, or treatment is one variety, is always vexing for providers. It's not only frustrating, it can be dangerous. Plus, as the New York Times quotes American Medical News: “Medical liability experts say missed appointments and failures to follow up pose some of the greatest legal risks for physicians.”

Strangely, we've actually found this very human issue to be one solved by technology. Telemedicine has proven invaluable in helping with patient compliance issues, specifically this problem of making sure that the patient sees the providers she needs to, in a timely fashion.

So if no-shows are something you struggle with in your practice, here are a few ways that telemedicine can help make a difference:

• Patients struggling to travel to a specialist can still be seen. For instance, veterans are increasingly accessing therapy appointments via telemedicine.
• A telemedicine consult can mean fewer appointments. Rather than patients bouncing from provider to provider to "collect" perspectives, a store-and-forward telemedicine platform can allow providers to synch up without the patient having to make an extra appointment.
• Followup is integrated. As the New York Times article points out, providers are often too squeezed for time to be able to follow up with patients to ensure they do what they're supposed to. Telemedicine can create a simple way for providers to check in with each other and make sure (in a matter of seconds) that the patient followed through.
• Providers can communicate without hassle. When doctors aren't playing phone tag, it's less likely that things (like appointments or referrals) can fall between the cracks. Telemedicine can make it easier for providers to communicate how and when is most convenient for them.

Ultimately, no-shows may not be providers' fault, but it is sometimes their problem. And we're glad that there's a tool that can help, even if just a little bit.