Abstract

Keywords: Primary care, e-medicine, telehealth, health care delivery, barriers to care.
Citation: Finn NB. Alternative sources of health care on every corner and in cyberspace. J Participat Med. 2016 June 17; 8:e8.
Published: June 17, 2016.
Competing Interests: The author has declared that no competing interests exist.

According to the Department of Health and Human Services, nearly 67 million people in the United States live in a primary care shortage area. For Americans who have a regular physician, only 57% report having access to same or next-day appointments, and 63% have difficulty getting access to care on nights, weekends or holidays without going to the emergency room. Over 20% of adults reported waiting 6 days or more to see a doctor when they were sick. [1]

The Association of American Medical Colleges predicts that the shortfall of doctors who are graduating from medical schools and who will go into general/family practice could be as high as 90,000 doctors by 2020. With total physician demand projected to grow by up to 17 percent, as baby boomers age, and with the Affordable Care Act universal coverage mandates that will increase the number of patients coming into the system by an order of magnitude, primary care physicians (PCPs), in particular, are going to be in short supply. The report estimates that between 12,500 and 31,000 primary care doctors that do not currently exist in our health care system will be needed. As a result, patients must look to alternative options for basic, sudden, non- emergency and routine medical needs. These service alternatives include retail and urgent care clinics and telehealth online services. For acute medical emergencies, patients should go to the closest emergency room. [2]

The Retail Clinic

In the past 12 months, Americans visited retail clinics for access to health services more than 10 million times a year at 1,800-plus locations. This represents approximately 2% of primary care encounters and is growing according to a study conducted by Manta Health, a health care consulting firm, and funded by the Robert Wood Johnson Foundation. By the end of 2016, the number of retail-based clinics is projected to reach 3,000. [3]

The retail care industry got its start in 2000, when the first retail-based clinic opened in Minnesota. Today, clinics are operating in major national pharmacy chains, including Walgreens, CVS, and Rite-Aid; in grocery stores such as Kroger, and in the “big box” stores such as Walmart and Target. They are typically staffed by nurse practitioners or physician assistants and treat routine maladies such as pink eye, ear infections, strep throat, cold, flu scrapes and bruises. They also provide immunizations and are expanding into wellness visits, routine physical exams, including school and camp physicals, chronic care monitoring for hypertension and diabetes Type II, and pregnancy tests. They offer services during evening and weekend hours, and present an alternative that is easily accessible for patients, as opposed to the difficulty of scheduling a timely appointment at a primary care physician’s office. The patients are primarily young adults (ages 18-44) and people without a basic health care provider. Visits are quick, typically lasting between 15 and 20 minutes and no appointments are needed.

When the patient arrives at a retail clinic, they sit down at a kiosk and choose their problem from the clinic’s menu of common complaints. Prices are clearly displayed to the patient/patron when they walk through the door. The cost of a visit ranges from $45 to around $100, depending upon the patient’s issue; a price point that is comparable to many patients’ co-payment for a standard medical visit, and considerably less than the cost of an emergency room visits. Most clinics accept health insurance. For the uninsured, the retail clinics offer basic preventive and clinical care services at prices considerably lower than they would incur in the ER or in urgent care clinics. Retail clinics also keep their costs down by limiting their services and their space. Exam rooms are about the size of a walk-in closet, and the retail clinics do not provide tests that require large diagnostic machines such as X-ray ultrasound, MRIs or CAT scans. [4]

Physicians have voiced their concerns about retail–based clinic care as fragmented and contrary to the Institute of Medicine’s push for the Patient Centered Medical Home where care is continuous and coordinated. However, all retail clinics offer the patient the option of sharing their visit summary with their primary care physician immediately. Providers at the retail clinics always suggest that patients follow up with their doctor as soon as possible. These clinics are intended to be a complement to the traditional model of care and the numbers and shortages in our health system today provide the real data to suggest that they are a necessity to ensure appropriate care to everyone in need.

Urgent Care Centers (UCCs)

Urgent Care Centers are another option for patients as an alternative to a visit to the emergency department or a way to find care when an individual’s primary care physician is unavailable. There are over 9,000 urgent care locations in more populous, affluent, higher-income areas of the country. They handle over 160 million visits annually. Approximately 30% of urgent care centers are owned by physicians or physician groups; 30% are owned by corporations, and 25% by hospitals. Another 7% are owned by non-physician individuals or franchisors.

Like retail clinics, urgent care centers fill an access gap by providing walk-in care, especially during evening and weekend hours, for patients without a primary care physician, or for those individuals who are unable to schedule a timely appointment with their PCP. UCCs primarily serve privately insured and Medicare patients, and nearly all urgent care clinics provide simple lab tests and basic x-ray services.

A study conducted by the Center for Study of Health Care Change that included 1,006 patients randomly surveyed, found that 54% of patients reported choosing the UCC because of the convenience of not having to make an appointment; 43.9% like UCCs because they get same day test results; 42.7% prefer them for the ability to get same-day medications; 67.9% of respondents reported that they do not have a personal primary care physician and 57.2% said they lacked a regular source of care. Despite a common belief that patients seek care in the urgent care clinics primarily for economic reasons, this study suggests that patients choose the urgent care setting based largely on convenience and more timely care. [5]

At both urgent care centers and retail clinics, providers are typically nurse practitioners and physician assistants, who are highly trained, qualified, and able to prescribe medication. Wait times are short and health plans generally will pay for the visit, and with a lower co-payment than patients would pay in their doctor’s office or in the ER.

Online Websites – Telehealth

Telehealth includes a broad scope of remote health care services including: clinical consults, provider training, administrative meetings, and continuing medical education. While one of the common perceptions of telehealth is of a patient speaking by videoconference with a remote physician, telehealth can take many forms. Telehealth technologies include:

• Videoconferencing
• Store-and-forward data, images or videos
• Remote patient monitoring
• mHealth (mobile health) applications

Some examples of how telehealth is used include:

• A pharmacist uses video conferencing to demonstrate how to use inhalers or the proper way to administer an injection. The pharmacist then and evaluates in real-time the patient’s technique and understanding of how to take their medicine.
• A physician based in rural Arkansas is able to examine his or her patient who is on a trip in Europe and sprained her ankle. Through a video telephone or a skype call, the physician can determine the severity of the sprain and what the best next steps would be to treat the problem.
• A patient who lives in rural Minnesota who was severely burned while fixing some farm machinery was airlifted to the regional burn center in Rochester MN 450 miles from his home. Upon his release he arranged to receive his follow up care via a video hook-up over the area’s telecare network.

A study in JAMA, conducted in 2013, described the impact of using telehealth for home blood pressure monitoring of patients with uncontrolled hypertension, with a device connected to the cloud. Real-time data were transmitted to a pharmacist remotely, who provided feedback to patients based on their blood pressure readings. Patients using the tele-monitoring device were 90% more likely to have controlled blood pressure. These results persisted even after the 12-month mark. Although the intervention was expensive (averaging $1,350/patient), it has the potential to be cost-effective in the long run, bringing better control and preventing expensive hospitalizations and billions of dollars in direct medical expenses. [6]

There are many online web providers now offering health care consumers 24/7 telehealth access to board certified doctors who conduct consults via mobile device, tablet or computer. The average cost for these telehealth visits is $50. Many of these services require a membership either through an employer or an insurer. Others are direct to consumer. Examples from some of these providers are outlined below.

eDocAmerica

The pioneer of online health care, founded in 1997, is eDocAmerica. Way ahead of its time, eDocAmerica was the vision of Dr. Charles W. Smith who wanted to empower patients to take more control of their health outcomes, by offering a service that would provide patients with online access to board certified physicians who could answer their questions and assist them with timely health situations.

Today, eDocAmerica includes primary care and family physicians, psychologists, pharmacists, dentists, dietitians, and fitness experts, as well as a 24-hour advice line staffed by a registered nurse. The service is used by more than 2 million individuals in all 50 States and over 70 foreign countries. These individual come to eDocAmerica via a phone app, a visit to the eDocAmerica website, or a visit to their insurer’s website. A response team forwards the patient’s questions to one of the eDocAmerica providers. Within an average of 24 hours the patient is connected directly with the provider and has an answer to their question. Providers who can respond in Spanish are also available. [7]

Teladoc

Teladoc, founded in 2002, employs more than 3,100 board-certified physicians and including: family physicians, pediatricians, specialists in internal medicine emergency medicine, dermatologists, psychiatrists, psychologists, and therapists who work in behavioral health. These health professionals handled more than 550,000 consults in 2015 via video, phone and visualized visits.

Teladoc users are referred from over 25 health plans, and more than 6,000 employers (many of them Fortune 1,000 companies), as well as several large hospitals and other institutions and organizations. Over 1.5 million telehealth visits have taken place using Teladoc’s services since their inception. For example, 18,000 Penske Truck Leasing employees have access to Teladoc as subscribers to Aetna health insurance. Over 20% of them used the service in 2015 and those numbers are increasing as Penske employees determine that they like the service because it provides them with care when they are on the road and need a quick health consult.

Dr Henry DePhillips, the Chief Medical Officer of Teladoc puts telehealth services into perspective:

“Telehealth is a win-win that provides a convenient alternative for patients who cannot easily access their own physician and need quick turnaround care, particularly at odd hours of the day and night, on holidays and weekends. We make it easy for companies and payers by providing an alternative that helps these companies support their employees and subscribers by bringing health care to patients, when and where they need it, via their smartphones and tablet computers, web browsers and land lines.” [8]

Teladoc clinical visits are never more than $45 regardless of the length of the visit, and 40% of Teladoc patients come back for repeat sessions. The average physician response time is less than 10 minutes. The cost for other specialties including Behavioral Health, Dermatology, Sexual Health or Smoking Cessation range, based on the individual’s needs. Teladoc is certified by the National Committee for Quality Assurance for its physician credentialing process.

Two years ago a Houston area school district signed up with Teladoc. One of their teachers, whose 7-year-old daughter has a recurrent history of ear infections, was running a high fever at 3 a.m. on Christmas Eve. The little girl’s mom called Teladoc on her mobile phone and explained to the doctor what she was experiencing. They discussed the symptoms, and based on the description, the Teladoc physician prescribed a medication. Teladoc also helped the family find the closest location where the medication could be obtained. A summary of the visit was sent to the child’s pediatrician the next day so that the child’s care could be followed through. This insured a happy Christmas Day for the family.

American Well (Amwell)

An elderly gentleman was hundreds of miles away from his home attending a family party when he suddenly felt a severe sinus headache coming on. He did not feel he could reach his primary care physician in a timely fashion, and certainly did not want to go to the ER and miss the party, nor did he want to drive around in an unfamiliar area to find a retail or urgent care clinic. So he went online and set up a video chat on Amwell with a board-certified physician practicing in Online Care Group, the nationwide medical affiliate of American Well. Their face-to face on screen computer connection enabled the physician to learn a lot about the gentleman’s symptoms. By instructing him to check his glands, look in his throat, press the area around his eyes for sensitivity, the physician was able to confirm that the patient had a sinus infection. She prescribed an antibiotic and within the hour he was happily celebrating with his family. For this direct to consumer visit, the patient was charged $49.00, significantly less than he would pay in the ER.

Similar to other telehealth services, the Amwell app offers access to basic clinical care, pediatrics, behavioral health consults, nutrition and dermatology. American Well is now moving into chronic care management. When a patient comes to the Amwell website they log in and choose from a menu of options that includes providing their health history, which becomes part of their Amwell digital record. This record remains in the Amwell system. The patient is then assigned a physician with whom they have a collaborative and interactive discussion. To close the loop, American Well makes make every effort to convince patients to authorize them to send a copy of the record to their primary care physician for continuity of care. A copy of that record is also sent to the patient.

American Well has been delivering telehealth services for over a decade. 65% of their visits are via mobile phone and 90% involve two-way video and audio either by mobile phone or a web browser. They also have kiosks in retail clinics, big box businesses and in many large factories and warehouses. All American Well physicians have at least 15 years of experience. They receive extensive training in how to work with patients with the proper “webside” manner. Every diagnosis is peer reviewed to maintain quality control in the care they deliver. Every patient fills out a patient satisfaction survey following their visit. Amwell’s behavioral health service has licensed social workers, psychologists and psychiatrists available. Patients pay $95 per visit which lasts for 45 minutes. On average, a patient might see the same therapist seven or eight times.

According to Mary Modahl, Senior Vice President and Chief Marketing Officer, “American Well works with over 600 major employers and many health plans. Fifty million Americans whose insurance covers their visit seek consults using Amwell each year. It is the most downloaded telehealth app with a 4.8 Star rating by the health care consumers who have used the system. Patients pay a $15 or $20 co-pay and gain admittance to see a physician with their subscriber identification. Women make up 52% of Amwell patients. The most common contact time is between 8 am and 10 am in the morning.” [9]

Karen, who was seeing a therapist for postpartum depression following the birth of her child, started using the Amwell behavioral health service to visit with her regular therapist who was in a private practice. This therapist was also a provider through an insurance company. Karen describes her Amwell experience as an “extension of care that enables me to better manage my health. I can have a session when I am traveling, while I am at work, or from my home. This allows me to keep balance in my life and at the same time prioritize my health while juggling my family, my job and my personal needs.”
Karen has had a dozen telehealth visits with her therapist over the past nine months in addition to her monthly face-to-face visits. “I just learned,” she says,” that my therapist may be moving to another location. But I am not concerned. I will be able to continue the telehealth visits and that would be just fine.”

American Well, recently launched AW9, its newest product release, featuring an industry-first multiway video solution that enables joint doctor appointments. Multiway video allows a patient or provider to invite other participants, such as a specialist, caregiver, health coach, family member or language translator into a live, video visit.

Doctor on Demand

Each year new telehealth services sprout up and Doctor on Demand, which launched its telehealth service in 2012 is the newest on the block. “With a heavy direct to consumer marketing focus and lots of television advertising,” according to Vice President and Chief Medical Officer Lena Cheng, “Doctor on Demand has popularized the telehealth concept and built an impressive stream of patients directly from consumers, as well as from employer and payer arrangements. They offer standard clinical services as well as pediatric care, psychologists, and lactations consultants.”
“Our goal, said Dr. Cheng, “is to practice medicine that is clinically superior. “We rely on the use of video technology to foster a patient experience that is more like a face-to-face clinical visit. Our five-star ratings in the App store and in Google Play reinforce the satisfaction of our patients.” [10]

Alternative Health Services Changing the Dynamic of Health Care

A study conducted in late 2015 by Oliver Wyman, an international consulting firm, that included 2,000 adults from diverse age, income, race and demographic backgrounds, revealed that nearly 80% of respondents liked their visit to the retail or urgent care clinic better or the same as their visit with their primary care physician. This is in sharp contrast to a similar study Oliver Wyman conducted in 2013 when only 15% of respondents had used a retail clinic and one third of the respondents were not even familiar with the concept.

Figure 1.

Graegar Smith, Principal at Oliver Wyman Health and Life Sciences Practice and the lead author of this study predicts “in the future we will see a lot of change and evolution as health care payers refine alternative sites of care strategies and as consumers become more open to finding care in locations that include grocery stores and mass retailers.

Smith also pointed out that “there are exciting times ahead in the telehealth space, as technology expands into new use cases, including behavioral health,” which he says, “becomes the secret sauce for making the user experience and underlying cost structures of physical sites of care better.”

Figure 2.

He also stated, “Traditional primary care providers are not going to go away. In fact, consumers were clear that they are only willing to receive certain types of health services in alternative settings. The “new front door” is not about replicating today’s health care system in a more convenient setting,” Smith said. “Instead, the new front door is about bolstering today’s health care system with a variety of consumer-friendly access points. The new front door is multi-dimensional (urgent care centers, retail health clinics, telehealth consultations, mobile apps). It is very clear that individually, none of these can deliver the full promise of the new front door. In fact, if offered as individual point solutions, consumer experience, health outcomes, and cost could suffer. An integrated new front door strategy, however, holds tremendous promise for consumers, payers, providers, and retailers alike,” he said. [11]

Many hospitals and large group practices also use telehealth to reach out to patient populations that are challenged by distance, limited mobility, and limited health literacy. Their primary purpose is to help them manage chronic conditions or assist patients with a wide range of diagnostic and rehabilitation therapies, including physical and occupational therapy, and speech therapy. Telehealth has proven to be effective in the delivery of specific instructions for a particular chronic condition, using an electronic hook-up to medical devices that the patient has in the home, and helping to educate patients and keep them on track. For example, patients send vital information about their blood sugar to a diabetes educator over a telehealth link and receive back instructions on how to adjust their diet or medication.

Pharmacies have assumed a large role in the future of telehealth, not only to provide convenience but to provide expertise as well. Medication therapy management, patient counseling, prior authorizations and refill authorizations, as well as the actual checking and dispensing of prescription medications, can all be done remotely by a pharmacist. [12]

Alternative health services of all types represent a paradigm shift in the delivery of health care to consumers which traditional medical practitioners are trying to come to grips with. Their concern is focused on coordination of care and the trusting relationships that patients and providers form when they have ongoing face to face encounters, Many providers contend that electronic visits be held only between a physician and established patients who previously received care from the specific practice. While this sounds logical, it is impractical when we refer back to the statistics that show the glaring shortages of primary care and family physicians, numbers that are only going to increase, leaving many members of our population without basic health care services.

Peter Elias, MD, a clinician who throughout his career has been a devoted advocate and practitioner of participatory medicine and collaborative patient care, views telehealth as “confirmation that the traditional system of care has failed patients so that they are forced to seek alternative services that provide them with the speed and cost efficiency that they do not find in the traditional health care setting. Dr. Elias points out, “What the patient risks losing is a deeper interaction with a clinician with whom they have a longstanding collaborative relationship and who has and uses their full record to good advantage. Sadly, many patients don’t stand to lose much as they don’t have this kind of care in the first place.” Dr. Elias could be right. [13]

However, when we look at the whole picture, we realize that these changes are inevitable, necessary and beneficial. Dr. Joseph C Kvedar, MD, a pioneer in telemedicine and the Founder and Director of Partners Connected Health says in his recently released book, The Internet of Healthy Things, “the convergence of several powerful economic, social and technological megatrends is creating upheaval in the health care system overcoming the headwinds that have been resistant to change.” [14

The time for alternative care sources is obviously here and now, and these new ways to provide care can only result in better outcomes and lower cost of care for everyone in need.

References

1. Projecting the Supply and Demand for Primary Care Practitioners Through 2020, published by the HRSA, Bureau of Health Professions and the National Center for Health Workforce Analysis, November 2013.
   http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/projectingprimarycare.pdf. ↩
2. The Complexities of Physician Supply and Demand: Projections from 2013 to 2025, IHS Inc. and the Association of American Medical Colleges, March 2015.Colleges
   https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf↩
3. Japsen, Bruce, Retail Clinics Hit 10 Million Annual Visits but Just 2% Of Primary Care, Forbes Magazine, Mar 24, 2016
   http://www.forbes.com/sites/brucejapsen/2015/04/23/retail-clinics-hit-10-million-annual-visits-but-just-2-of-primary-care-market/#1d5db5cf3891 ↩
4. Retail-based Clinics Increase Consumer Access to High Quality, Affordable, and Convenient Primary Care Services, Supporters Say, Robert Wood Johnson Foundation, February 20, 2015
   http://www.rwjf.org/en/library/articles-and-news/2015/02/growing-retail-clinic-industry-employs–empowers-nurse-practitio.html ↩
5. Yee, Tracy, Lechner, Amanda E., Boukus, Ellyn R., The Surge in Urgent Care Centers: Emergency Department Alternative or Costly Convenience? HSC Research Brief No. 26 July 2013. http://www.hschange.com/CONTENT/1366/#ib1 ↩
6. Margolis, Karen L., MD,MPH, Asche, Stephen E, MA, Bergdall, Anna R. MPH, et al, Effect of Home Blood Pressure Tele monitoring and Pharmacist Management on Blood Pressure Control A Cluster Randomized Clinical Trial JAMA. 2013;310(1):46-56. doi:10.1001/jama.2013.6549. http://jama.jamanetwork.com/article.aspx?articleid=1707720&resultClick=3 ↩
7. Interview with eDocAmerica, Robbie Linn, President eDocAmerica. https://www.edocamerica.com/default.aspx? ↩
8. Interview with Henry DePhillips, Chief Medical Officer, Teladoc. https://www.teladoc.com/ ↩
9. Interview with Mary Modahl, Senior Vice President and Chief Marking Officer, American Well. https://www.americanwell.com/ ↩
10. Interview with Lena Cheng, President and Chief Medical Officer, Doctor on Demand. http://www.doctorondemand.com/ ↩
11. The New Front Door to Health care is Here, Oliver Wyman Inc. Health & Life Sciences, copyright 2016. http://www.oliverwyman.com/insights/publications/2016/mar/new-front-door-to-health care.html#.VvGS800UUkI ↩
12. Telemedicine: New technologies, new normal, American Pharmacists Association, September 01, 2013. https://www.pharmacist.com/. ↩
13. Interview with Peter Elias, MD. ↩
14. Kvedar, Joseph C. MD, Colman, Carol, Cella, Gina, The Internet of Healthy Things, Partners Connected Health, 2015, p. 25. ↩

Copyright: © 2016 Nancy B. Finn. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.