Telehealth is the future but it is obscured by a dismal present [PODCAST]

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“Will the unfavorable regulatory environment permit telehealth to flourish? Perforce we’re beginning to see a relaxation of restrictions that have hitherto obstructed progress.  Recently, federal officials approved interstate licensing, thereby prompting greater telehealth conversion, utilization, and expansion. Medicare’s 1135 Waiver is also encouraging, and, in as much as it serves the same ends, the Drug Enforcement Administration’s leave to prescribe via telemedicine without a prior in-person meeting is a  similarly promising development. In light of circumstances, anything that might reduce cost, improve delivery, and wrest control from bloated, dysfunctional health care systems is viable.”

David Hanekom is an internal medicine physician.

He shares his story and discusses his KevinMD article, “Telehealth is the future but it is obscured by a dismal present.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have David Hanekom. He is an internal medicine physician, and he wrote the KevinMD article “Telehealth is the future but it is obscured by a dismal present.” David, welcome to the show.

David Hanekom: Thank you very much, Kevin.

Kevin Pho: First off, can you share your story and your journey to where you are today?

David Hanekom: Yes, certainly. As you can hear from my accent, I’m from the deep south. I grew up in South Africa, trained in Johannesburg at Wits, and subsequently had the privilege of working in multiple countries as a primary care physician over the last 20 years, diversifying my training and experience by moving from clinical practice to the payer side and then to the software development side, to continue my mission, which is essentially to make sure that we have a better health care system and that we always keep the best interest of the physician and the patient at the center of everything we do, because really, that is the core of the health delivery system.

Kevin Pho: And how is the pandemic affecting your professional life?

David Hanekom: Well, it’s very interesting. I am the chief medical officer for a large international company that specializes in the application of blockchain. And so I have routinely traveled to Kiev in the Ukraine two weeks per month for the last year and a half. I’ve had to curtail that, and so my life has moved to isolating myself and to a virtual engagement of the various stakeholders in our business, and that’s certainly been very challenging.

Kevin Pho: So let’s get into your KevinMD article, “Telehealth is the future but it is obscured by a dismal present.” For those who haven’t read your article, can you walk my audience through it and share the story of why you decided to write it?

David Hanekom: That’s a very interesting story, you know. I am, like most physicians, a traditionalist, believing in the doctor-patient relationship being a face-to-face, in-person one. And what happened with telemedicine being launched across the United States and various other countries is it was used predominantly to decompress emergency room utilization, by the payers and various others. So it was kind of a sideline for the large delivery systems.

When the pandemic hit, and we finally had a threat that was an equal threat to both the clinician, the physician, and their patient, i.e. the pandemic virus, we were suddenly left in the lurch. And so everybody had to change their clinical practice model and tended to gravitate to whatever telemedicine solution they could get. And it very quickly became clear that the telemedicine solutions in the marketplace were just not meeting the needs of clinicians and patients.

So, for example, I have a chronic condition, and I have had to move all my care with my care team to virtual for the last six months. And despite the complexity and the cost of the various technology platforms that the health systems that care for me have in place, my virtual visits still occur by FaceTime or Zoom. And it’s interesting to talk to my colleagues, who are saying, “We were never prepared for this. We were not trained to manage a relationship virtually.” How do you take the short time that you have and have a meaningful discussion with a patient while appearing empathic and listening? And the tools that they still have today were not designed for this new world. And so where we are right now is everybody’s really in the lurch in terms of how do I get the best-quality relationship with my patients with the technical limitations that they have.

Kevin Pho: So just to be clear, what’s wrong with having a virtual visit on FaceTime or Zoom?

David Hanekom: Well, from a physician perspective, physicians are still entering data into the EMR system. The virtual visit component occurs on another technology platform, and the two are not integrated. And so there are not only issues with data sharing and information sharing, but also with meeting the various documentation mandates. This is adding an additional burden on the average physician, who not only has to deal with the complexity of the EMR environment in which they’re working, but now they have to sync and make sure that they’re on time for a virtual visit, et cetera, et cetera. That’s adding additional complexity.

And then you add to that the complexities of billing for virtual visits, which are not being made easy by the various payers. And there is the mere fact that patients are gravitating to the most available online physician, which may not be the physician that they actually have a personal relationship with, who has a better contextual knowledge of their health. And so I think patient care will suffer if we can’t maintain that direct relationship with a clinician who knows the patient very well.

Kevin Pho: So I can certainly attest to what you’re saying. I’m an internal medicine primary care doctor myself, and we had to adapt to a virtual platform literally within days. And I think a lot of what you’re saying certainly applies to a lot of other doctors across the country. Now, we’ve been in a pandemic for eight to nine months now, and virtual visits are slowly dying down, and now more people are coming into the office. Now, given that time, what are some of the solutions that you see, should we need to adopt virtual visits more broadly again?

David Hanekom: I think so. I think it first depends on how you view the pandemic: whether you believe it is a short-lived aberrancy in what happens in the environment, or whether you believe that the coronavirus is here to stay, that we will learn how to manage it better, and that we’ll make changes in our behavior and in our practice patterns in order to accommodate that. I believe in the latter.

What is critical in terms of the virtual component of practicing medicine is that it be fully integrated with other activities, including care coordination, managing chronic conditions, and providing acute versus chronic care, and that we think of virtual medicine or telemedicine components, especially the video visit component, as a mechanism by which to continue the care coordination activities that are absolutely critical for the vast majority of patients. So if you look at what our challenge is, for example, it is not only how do we support the doctor-patient relationship and make sure that patients get better access, that they get safe, secure access, and that virtual medicine is combined with an ability to access local care to do the other things that can’t be done virtually.

There is a significant disparity, as you’re well aware, in the distribution of physicians. Physicians are rare resources across the world. There are countries where there is one physician for every 400 citizens, and there are others where there is one physician for 100,000 citizens. And so, from an equity perspective, there’s a real opportunity with virtual medicine to grant patients all over the world access to highly trained clinicians who can do virtual visits, give them advice, listen to their story, and help guide them in terms of getting local care.

I hope that with the pandemic, one of the silver linings is that we would start thinking of physicians all over the world as resources that should be distributed better, and of virtual medicine as a way to allow patients all over the world to get access to physicians in different parts of the world or different parts of the country. The complexity is dealing with the regulatory, the licensing, and the various other activities that were initially designed to protect the patient and physician and make sure that good-quality medicine is provided but subsequently, I would say, over the last few decades, have become anti-competitive in manner. It’s more about protecting the local market than really giving patients access to highly skilled clinicians from all over the world. And so there’s an opportunity to think more broadly of the use of telemedicine in terms of community development and access for patients and physicians on a global scale, as opposed to just local.

Kevin Pho: Now, of course, one thing that’s going to play a role in whether telemedicine survives or not is the payers, right? Whether telemedicine is going to be reimbursed going forward. Of course, we’re in a pandemic, and Medicare and private payers paid for virtual medicine, but there’s no guarantee they’re going to do so going forward. What’s your opinion on that?

David Hanekom: It’s problematic. Certainly, CMS in the United States taking a position to provide waivers, et cetera, and allow greater access for their beneficiaries to physicians and telemedicine was a very good move. And most of the payers followed that. It is unfortunate to see that most of the major payers are dialing back their reimbursement. It’s part of the legacy of cognitive physician services being valued less than procedural services. I think that’s a big mistake.

I also think that what many physicians have learned and what patients have learned is, one, there is a different way to get more personal access to your own physician without having to travel and having to deal with all the bureaucracies associated with in-person care. And the second realization for physicians is that you can have a meaningful relationship with your known patients and build new relationships virtually, and that you do not have to practice only in the person-to-person, face-to-face mode. So I think many physicians are looking at telemedicine solutions that give them more control over their professional lives.

Example being, not only are physicians reimbursed less for virtual visits than in-person visits, but the payers are beginning to scale back. And so the payers are very much focused on making a physician available at a very low unit cost and have very little interest in maintaining the relationship. And I maintain that that relationship is really critical to protect the patient, because interpreting without the context of the patient, the family, and their society is fraught with danger.

So I expect many physicians are considering starting their practices in a virtual world and then selectively allowing patients to access them in person as part of their practice model. And if that’s the case, and I do believe it will be, then many of them will say, “I’m also going to set my own rates. I can charge more for a virtual visit and meet the needs of my patient and the care that they need to get. I can partner with other clinicians and health care providers.” And if you do it right, and if the technology is developed correctly, then much of the administrative cost associated with running a practice as a business will go away with proper design. And so I suspect you’ll see a decrease in telemedicine visits over the next few months, and then you’ll start getting the direct primary care virtual model, with some in-person restricted practice model, becoming much more attractive to physicians. And they’ll untether themselves from the payment systems of the payers.

Kevin Pho: We’re talking to David Hanekom. He is an internal medicine physician, and he wrote the KevinMD article “Telehealth is the future but it is obscured by a dismal present.” David, what’s something that you’ve learned during the pandemic that you wish you knew back before it started?

David Hanekom: You know, I never realized the vulnerability of physicians. You and I have heard over the last few years about burnout and how physicians are feeling like widgets, that they feel that they have less control over their professional life, and that their ability to act as the advocates for the patient is being more and more impeded by the bureaucratic and administrative regulatory environment that they live in.

What has become very clear to me, which was shocking, and I see this both in the area I live, where my son is a practicing physician, and in talking to my colleagues internationally, is that physicians lost their jobs. Physicians had their incomes reduced significantly, not because of patient factors in the pandemic, but because the systems that employed them thought that they could cut back on their commitments to clinicians in terms of salary guarantees, et cetera, et cetera, and that they could just shut certain departments down because they no longer met their economic model needs.

That kind of threat to a physician’s sovereignty and a physician’s financial well-being, even in an employed model, during a time of a health care crisis, where you would expect a greater demand on physicians’ time, their skills, et cetera, and the associated rewards, was a shock to me. Because generally, in times of economic crisis or health crises, physicians are brought to the forefront and do very well because of their unique skill set. So that was a surprise to me. Many clinicians that I speak to tell me, “You know what? I’m not as secure as I thought I would be,” for example, as this type of specialist in this health system in New York or anywhere else in the world. So that was a learning for me.

The second thing that was important is the need for humans to have physical interaction with each other. As people move to a remote work environment and isolation, the exacerbation of behavioral health issues, and the stresses associated with that, apart from the economic impact, is really having a significant impact, not only on my colleagues and myself, but also on their patients. And that’s something we should think about very carefully as we talk about, “Let’s remove telemedicine coverage or reduce the unit costs because there’s greater competition,” from a payer perspective. It would be a mistake from a public health perspective.

Kevin Pho: Now, just a follow-up question on your first answer. Of course, I know a lot of physicians who are cutting back, or they’ve been furloughed and laid off. Now, from a hospital standpoint, why is that such a short-sighted decision to cut physician salaries?

David Hanekom: It is very unusual for hospitals to cut physicians’ salaries, because they’re so dependent on those physicians bringing services into the institutions, where the infrastructure costs are unsustainable. I think it is because, to a large degree, physicians’ power in terms of economic policy, practice policy, and business acumen within the large institution-driven systems has been minimalized or sidelined over the last few years. And so I want to make a very strong argument for physicians to take leadership positions and to demand a say at the table, and a place at the table, where they can lead the entire ecosystem related to health care.

I recall, Kevin, when I was a young man studying medicine at Wits in Johannesburg in the early ’80s, one of my professors said to me that a physician has legitimate purview over any matter that impacts the health of their patient. In other words, you should not limit yourself to the pure science, the pure art of medicine. You must look at the context of your patient, the public policy, whether it be politics, school policy, roads, infrastructure, et cetera. If it impacts your patient and their family, you have a legitimate role if you so choose.

And so my argument, my ask and call to action to physicians, is that we can complain, or we can step up. Take your unique experiences and your training. Think of yourself as the advocate for all your patients, be that a few hundred, a few thousand, a state, or a country, and play your legitimate role, which means you have skills and you have experiences that you can extend, as part of your clinical training, to society as a whole. And if it’s in the best interest of the patient. In my opinion, the best interest of the patient, broadly speaking, is also the best interest of the physician. And so I think that message is critical, as patients become unhappy with how they access the system, how they are treated, and the outcomes they achieve. You see a common dissatisfaction among physicians as well. So get involved. You can make a difference. One person can make a significant difference.

Kevin Pho: My final question: You have a take-home message that you want to share with the KevinMD audience?

David Hanekom: Talk to each other. We are a very vulnerable community. We have a very heavy burden put on physicians, not only by virtue of their training and licensure, but remember, the pandemic and all the conditions and afflictions that impact your patients may and will impact you and your family as well. So it’s personal. Take care of yourself. Make sure that you can tell the difference between the necessary work and unnecessary work. And as much as possible, spend time with your family, because none of us can predict what’s going to happen tomorrow. This pandemic was an academic exercise in terms of planning for decades, and then it hit.

And so all of us, I think, are reassessing how we live, how important those relationships are, and how we need to make sure that we have whatever work-life balance, and I can’t define that for you, whatever that means for you, to remain well and healthy as a physician, which is necessary for good patient care.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

David Hanekom: Kevin, you’re most welcome. Thank you very much for the opportunity to speak with you.

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