Telehealth to Expand Access to Expertise and Treatment Relationships, Not to Commoditize Care

Big news in digital health this week with several pharmacies putting a pause on filling telehealth company-driven prescriptions.

Mohana Ravindranath interviewed me and wrote a thoughtful piece in STAT News capturing so much of the nuance. The broader story could easily turn into a media pile-on against telehealth, which I think would be a mistake. I previously wrote with Judd Hollander in NEJM Catalyst, discussing the need for telehealth to mature from adoption to quality-based metrics.

I think this week we're seeing a continuation of the same theme: telehealth in itself does not describe nor capture quality. Telehealth is simply a way of delivering care, and that underlying care, just like in-person care, can be either high or low quality. There is no doubt that today's American health system is not meeting the needs of many patients, especially those with chronic, complex medical conditions, by failing to provide everyone with easy access to high-quality, affordable care. Within this, far too many patients cannot access a high-quality, caring doctor-patient relationship. Far too many patients cannot get convenient, affordable access to the medications they need. It is wonderful that there are entrepreneurs looking to innovate toward solving these substantial challenges and there are so many doing great work.

In some cases, there are digital health companies, fueled by growth demands, who look at this problem and view the doctor-patient interaction as a commodity, who believe that the problem is just a prescription medication issue. I think they're making an erroneous assumption – that a doctor-patient relationship is irrelevant. And, I think they are asking the wrong question, “How do we remove all friction between a person and a prescription?" They see patients leave a doctor's visit with a prescription and mistakenly believe the prescription is the product of the healthcare interaction. They fail to see that a healthy, high-quality doctor-patient relationship should be so much more than that. This framing imposes significant risks by incentivizing frictionless, high volume prescriptions and potentially losing the other elements of high-quality care.

Frictionless prescriptions can actually be a very good thing! No question, for people who have established chronic conditions, and established healthcare, there is too much friction in the system making it too hard for people to get their medications. As an endocrinologist, people I care for with diabetes have far too difficult a time accessing the insulin they need. Innovations and systemic changes to reduce friction and barriers are needed. The problematic issue occurs when the frictionless prescription is the only thing.

Similarly, telehealth is not the problem. As we have seen throughout the pandemic, telehealth has proven to be an effective, safe method for so many people to get convenient access to high-quality healthcare. And the future opportunity is even greater. Today, access to expertise is often limited by geography – telehealth decouples this. A company can now set itself up to deliver care on a national scale and can use targeted digital marketing to identify and attract a very specific type of individual as a customer. This capability could be used to great benefit. For example, enabling people from rural or remote areas much easier access to certain specialists or expertise that may not be available in all geographies, such as a world expert in a rare lipid disorder. Or, conveniently providing digital diabetes coaching to a broad spectrum of people. Of course, this same capability can also be used to rapidly target and identify customers via web searches from all over the country, and present to them the option of a prescription without the responsibility of a treatment and care relationship.

I hope recent events do not get construed as a reason to put onerous limitations on telehealth. Instead I hope we can all view this through the appropriate lens. Healthcare has never been free from fraud or from providers who give out a prescription to anyone who comes in the door. Yes, the speed and scale offered by digital marketing and a telehealth-driven model may increase the potential size and scale of bad actors. But, telehealth did not invent this problem, and restricting telehealth won't solve it. We instead need to focus on innovative ways to cultivate high-quality care relationships and to leverage digital capabilities, including telehealth, as a fantastic opportunity to bring scale, convenience, and efficiency.

Aaron Neinstein, MD