Kaiser Permanente, the huge integrated health and insurance system, had a $1 billion operating gain in the first quarter of 2017 with $18.1 billion in revenue. That’s way up from the year-earlier $701 million operating gain on $16.3 billion in revenue.
The system had a 5.5 percent operating margin in the first quarter, up from 4.3 percent in the first quarter of 2016.
KP has been quite successful in shifting to value-based care and increasing use of telemedicine.
Kaiser Permanente’s CEO, Bernard Tyson, recently said more than half of KP members’ physician visits were virtual, partly because $3.8 billion of its annual capital spending is IT-related.
The organization has long been know for its high quality of care and emphasis on preventive care, its salaried physicians (which means less likelihood 0f unneeded, fee-for-service procedures to drum up income), and efforts to minimize the time that patients spend in high-cost hospitals.
PlushCare, an online urgent-care company, has introduced ‘’Lemur,’’ what the firm calls the “first ever electronic medical record (EMR) system for the telehealth industry.”
The company says that Lemur requires fewer clicks to complete tasks than older EMR systems, which simplifies physicians’ workflow and lets them spend more time with patients. James Wantuck, M.D., the company’s chief medical officer and a co-founder, told Healthcare Dive that the time spent on the platform was only half that of a third-party EMR systems telemedicine physicians used previously.
Dr. Wantuck told Healthcare Dive that physicians designed Lemur. With it, physicians can “establish this virtual relationship with someone where you’re not typing into a computer, there’s nothing between you and the patient.’’
The news service said that PlushCare currently operates in 16 states and plans to expand particularly in rural areas where access to care has been increasingly difficult because of the wave of rural hospitals being closed.
Just before dusk on an evening in early March, Mimi Rosenkrance set to work on her spacious cattle ranch to vaccinate a calf. But the mother cow quickly decided that just wasn’t going to happen. She charged, all 1,000 pounds of her, knocking Rosenkrance over and repeatedly stomping on her. “That cow was trying to push me to China,” Rosenkrance recalls..
Dizzy and nauseated, with bruises spreading on both her legs and around her eye, Rosenkrance, 58, nearly passed out. Her son called 911 and an ambulance staffed by volunteers drove her to Lost Rivers Medical Center, a tiny, brick hospital nestled on the snowy hills above this remote town in central Idaho.
Lost Rivers has only one full-time doctor and its emergency room has just three beds — not much bigger than a summer camp infirmary. But here’s what happened to Rosenkrance in the first 90 minutes after she showed up: She got a CT scan to check for a brain injury, X-rays to look for broken bones, an IV to replenish her fluids and her ear sewn back together. The next morning, although the hospital has no pharmacist, she got a prescription for painkillers filled through a remote prescription service. It was the kind of full-service medical treatment that might be expected of a hospital in a much larger town.
Not so long ago, providing such high-level care seemed impossible at Lost Rivers. In fact, it looked as if there wouldn’t be a Lost Rivers at all. The 14-bed hospital serves all of Butte County, whose population of 2,501 (down from 2,893 in 2000) is spread over a territory half the size of Connecticut. Arco, the county’s largest town, has seen its population drop 16 percent since 2000, from 1,026 to 857 last year. “Bears outnumber people out here,” is how hospital CEO Brad Huerta puts it.
The medical center nearly shut its doors in 2013 due in large part to the declining population of the area it serves — almost becoming another statistic, another hospital to vanish from rural America. But then the hospital got a dramatic reboot with new management, led by Huerta, who secured financing to help pay for more advanced technology, upgraded facilities and expanded services. He also brought in more rotating specialists, started using telemedicine to connect the hospital to experts elsewhere and is now planning to open a surgery center and a long-term care rehabilitation wing.
If Lost Rivers had closed, the alternative would have been hospitals in Idaho Falls or Pocatello, each more than an hour away across high-altitude prairie. Instead, “I don’t have to go across the desert for hardly anything,” said Rosenkrance, resting at the hospital the morning after the cow attack.
Rural hospitals are facing one of the great slow-moving crises in American healthcare. Across the U.S., they’ve been closing at a rate of about one per month since 2010 — a total of 78, or about 6 percent. About 14 percent of the U.S. population lives in rural counties, a proportion that has dropped as the number of urban dwellers grows. Declining populations mean a smaller base of patients and less revenue. And the hospitals are caught in a squeeze: Because many patients in the countryside are older and sicker, they require more intensive and often expensive care.
Faced with these dramatic economic and demographic pressures, however, some hospitals are surviving — even thriving — by taking advantage of some of the most cutting-edge trends in health care. They are experimenting with telemedicine, using remote monitors to track patients and purchasing high-tech equipment to perform scans and other types of exams. And because many face physician shortages, they are partnering with universities and increasingly relying on nurse practitioners, paramedics and others to deliver care. In parts of rural Oregon and Washington, veterans can get counseling through a tele-mental health program. Physicians in Iowa and North Dakota have access to virtual emergency room support.
At Lost Rivers — a dramatic rural health turnaround story — Huerta’s strategy was to use technology and innovation to offer the kind of high-quality medical care that would keep patients like Rosenkrance coming back. “Necessity is the mother of invention,” Huerta said. “Small hospitals like mine are always going to be under the gun. You have to get really creative.”
In the decades to come, America’s heartland and hinterlands will continue to be home to the people who run the country’s farms, forests and fisheries, and its wilder regions will continue to draw visitors who crave nature and recreation. And those people will need medical care. As a result, rural health researchers say hospitals like Lost Rivers are important test cases. They show that, despite daunting obstacles, rural America need not be left behind when it comes to health care. In fact, because they are being forced to innovate faster than their urban counterparts, they can provide a glimpse into the future of medicine.
“Being in a rural place does not preclude high-quality medicine,” said Tom Ricketts, senior policy fellow at the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. “They are under a lot of pressure, but there are rural places you can point to as places you would say, ‘This is how things ought to be done.’”
Where Folks Wear ‘Multiple Hats’
It’s a Tuesday afternoon at Tara Parsons’ flower shop. She cleans up as she waits for customers — or for an emergency call. Parsons, a fourth-generation Arco resident, is not just the town florist; she is also the county coroner, a sheriff’s dispatcher and a volunteer emergency medical technician. This afternoon, she is on ambulance duty.
“We all wear multiple hats out here,” she said.
The streets are lined with shuttered and boarded-up storefronts, some with their signs still on display: the Galloping Goose, the Sawtooth Club. Residents talk nostalgically about the town’s heyday, when there were banks, a bowling alley and a movie theater, back when residents drove to Idaho Falls only twice a year, to get school supplies and do Christmas shopping.
The town of Arco was founded in the 1870s as a junction for horse-drawn stagecoaches. Its quirky claim to fame is that in 1955, it became the first town in the world to be powered by nuclear energy, a credit to the Idaho National Laboratory, down the road toward Idaho Falls. Every summer, to celebrate its history, the town puts on a celebration that features a rodeo and a softball tournament.
Now, most of the businesses are gone. The town still has a lumber shop, a hardware store and a few auto garages. There’s also a bar, a gym and a dollar store. And around the corner there’s the local diner — Pickle’s Place — where people come day and night for fried pickles and biscuits and gravy.
Like so many other residents, Butte County clerk Shelly Shaffer has a personal connection to the hospital: Her mom worked there, her sister was born there, and she used to take her children there. Lost Rivers Medical Center — which also has two outpatient clinics — is one of the town’s biggest employers.
“It would be devastating if we didn’t have our hospital,” she said.
That was the direction they were headed. When Huerta, the CEO, arrived four years ago, he found the nearly 60-year-old hospital in disarray — dilapidated facilities, fearful employees, reluctant patients and a financial mess left behind by the former CEO. The hospital’s bank account held just $7,000 and morale was at an all-time low. “We were the poster child for everything that was wrong with rural health care,” he said. “It had been a slow, steady decline from neglect.”
Shannon Gamett, 28, a nurse at Lost Rivers, said paydays were nerve-wracking: “We would run as fast as we could to the bank to cash [a paycheck], or it might not clear.”
After borrowing money to pay his employees, Huerta campaigned to pass a $5.5 million bond for Lost Rivers. He asked locals if it was worth $5 a month — one six-pack of beer or two movie rentals — to keep the hospital running. They answered “yes” at the polls, and the hospital emerged from bankruptcy. Next, Huerta set his sights on overhauling the badly outmoded facilities. One of his top priorities was the laboratory, which he said looked like a high school science classroom from the 1950s.
He instituted a new philosophy: If it doesn’t happen at a “real” hospital, it doesn’t happen at Lost Rivers. That meant ending some local practices, nixing little things like letting staff members wear scrubs of any color they fancied, and big things, like allowing people to bring their horses in for X-rays. “I said, ‘I have no problem doing this, but you tell me what insurance the horse has,’” he recalled. “The practice stopped immediately.”
To bring in more revenue, he applied for grants and got the hospital a trauma center designation (the first level IV trauma center in Idaho) so it could get paid more for the care it was already providing. He saved money by inviting the town’s residents to help renovate clinic exam rooms and by moving the medical records to a cloud-based system that didn’t require more information technology employees.
Prognosis Unclear
Despite Huerta’s efforts, however, the long-term success of Lost Rivers is not guaranteed. “If you don’t have enough people to support a clinic or a hospital, it has no economic reason to be there,” said Ricketts, the Sheps Center fellow. “It just disappears.”
Arco and Butte County officials hope the local economy will get a boost from a planned expansion of Idaho National Laboratory, which conducts nuclear energy testing and research. Residents also are mounting a campaign to get the Craters of the Moon, a national monument in Butte County, designated as a national park.
“It would literally put us on the map,” county clerk Shaffer said.
But even if that happens, Huerta knows he can’t expect a big influx of new residents. Rural parts of the United States saw an absolute decline in population following the 2008 financial crisis, a trend that has since stabilized. But there is little or no growth. So Huerta has to concentrate on keeping the patients he has — and giving them a reason to keep coming. And it’s working: The hospital is now making a small profit and has some reserves on hand for future projects.
“If you are not offering the services, people are going to go somewhere else,” Huerta said. “And as medicine advances and reimbursement is still pegged to volume, you have to find ways to keep that existing population here.”
One big challenge for Lost Rivers and many other rural hospitals is that their patients tend to be older — and thus sicker and costlier to treat. People 65 and older account for about 18 percent of the rural population, compared with 12 percent in urban areas, according to the National Rural Health Association. An older patient base can strain hospitals because Medicare, the public insurance program for the elderly, doesn’t pay hospitals as well as private insurance does. Elderly patients also may need more intense care than small hospitals can provide.
Some seniors move to Arco precisely because there is a hospital in town. But for others, what Lost Rivers offers simply isn’t enough.Rural hospitals have a higher percentage of patients on Medicaid, the public insurance for poor people, which pays notoriously low rates to providers.
Residents Ray Westfall, 82, and his wife, Winona, recently put their house on the market after deciding it was time to move to Utah, closer to family and more specialized health care. Westfall has neuropathy in his legs, which causes numbness most of the time. He gets around with a walker. Winona has dementia.
“We can get some care here at the local hospital, but mostly we have to travel to Idaho Falls,” he said.
Westfall is a regular at Parsons’s flower shop. On a recent Tuesday, he bought a bouquet for his wife — carnations, her favorite.
Parsons said many of the emergency calls she responds to are for older folks who’ve suffered strokes, fallen at home or are struggling to breathe. One 99-year-old woman she took to the hospital on this morning had fallen in her living room.
Parsons said she has known many of her patients for years, through her parents or grandparents. As they grow old and get sick, she picks them up in the ambulance and drives them to Lost Rivers.
“And before long, I’m doing their funeral flowers,” she said.
Telemedicine: A New Frontier
At first the Bengal Pharmacy, on the bottom floor of Lost Rivers Medical Center, looks like any other pharmacy, with racks of over-the-counter cold medications, bandages, reading glasses and medical supplies. Shelves of prescription medications sit behind the counter. But it has no pharmacist on site; instead, technicians and students from Idaho State University in Pocatello shuffle about, filling prescriptions.
Their supervisor is a pharmacist at the university, about 80 miles away, who checks their work remotely. Patients who want to talk to him go to a small private room with a phone and video link. The pharmacy is named for the university’s mascot.
For rural hospitals, telehealth can make otherwise faraway services accessible to people where they live, said Keith Mueller, director of the Center for Rural Health Policy Analysis at the University of Iowa. That can be critical, especially during the winter when snowstorms sometimes cut off access to rural towns.
“We can, in effect, bring the provider to the community without physically doing so,” Mueller said. “Even in urban areas, people want more and more convenience in how we receive our services. Here we are talking more about necessity.”
At Lost Rivers, patients can have telemedicine appointments with a psychiatrist. And doctors can get virtual guidance from specialists in trauma, emergency care and burns. But new technologies sometimes take getting used to. “When you lose that hometown community pharmacist, that human touch, when you turn it over to computers, that’s a concept that people have difficulty with,” said Martha Danz, who sits on the hospital’s board.
Leon Coon, 83, said the concept is a bit foreign to him. “I just don’t do that stuff,” said Coon, who works loading hay. “I’m a little old-fashioned.” Sipping coffee at the truck stop early on a Wednesday morning, Coon said he doesn’t even text, so he’s a bit wary of technology that puts him in touch with a pharmacist all the way in Pocatello. But then again, he said he doesn’t rely on the medical system much at all.
“Anytime you go to the doctor, it’s just like a mechanic,” he said. “They’re going to find something wrong. I feel good most of the time, so I just don’t go.”
Shane Rosenkrance, whose wife got trampled by the cow, said he remembers when there were five community drugstores in the valley. Now, he is grateful to have the one pharmacy — even if the pharmacist isn’t actually behind the counter. “To have health care, you have to have a pharmacy,” he said. “And through technology, they are able to do it.”
Telemedicine is hardly a panacea. The projects often depend on grants or government awards, because rural hospitals’ operating margins are slim. And some of the telemedicine and remote monitoring technologies require high-speed internet, which isn’t always reliable or cost-effective in rural areas.
“You can’t do home monitoring everywhere,” said Sally Buck, CEO of the National Rural Health Resource Center. “You can’t do telehealth everywhere.”
“Ego is a dangerous thing,” he said. “If there is anyone who can do a better job, I’m going to get [my patients] there.”Telemedicine also may raise more questions than it answers for some patients, and even create a need for in-person follow-ups. Orie Browne, the medical director for Lost Rivers, said he tries to keep patients from having to travel. But if someone needs more advanced medical care — or a specialist that Lost Rivers doesn’t have — he will refer them to another hospital. The hospital has a helicopter pad, and patients with emergencies that can’t be handled at Lost Rivers can either be flown out by helicopter or transferred by ambulance.
Nevertheless, Huerta said, he hopes to expand telemedicine, including such services as oncology. Huerta recognizes that Lost Rivers doesn’t have the staff or the expertise to do it all. He believes the hospital should try to do more when it can, and refer out the rest.
“We aren’t trying to do brain surgery,” he said. “We’re not doing Level I trauma. But colonoscopies? Tele-oncology? People in rural areas get cancer too, and it’s demanding driving hours back from a chemotherapy session.”
Rounding Up Doctors
Browne started work at Lost Rivers one recent day in March, then drove 45 minutes to one of its outpatient clinics in Mackay, 26 miles away. One of his first patients was Elizabeth Galasso, 59, who was worried because her heart rate was racing.
“I was scared,” Galasso said, speaking with a hoarse voice as she sat hunched on the exam table. “I felt my heart pounding clear down into my stomach.”
An EKG showed her heart was beating normally. Browne told her it was likely a panic attack, but suggested a stress test just to make sure. He told her that her age, her smoking history and anxiety all put her at risk for heart disease.
“But I think things are going to be just fine,” he said. Galasso reached over and hugged him.
Browne, who took over as Lost Rivers’s medical director in 2015, said he was drawn to the outdoor activities in the area — and the variety of rural health care. He used to have a private practice in Idaho Falls and rotated into Lost Rivers for a week at a time. Now, he spends his days bouncing between the emergency room, the hospital inpatient beds and the primary care clinic. “That’s good for a person who gets bored easily,” he said.
Many doctors, however, don’t feel the same pull. Rural hospitals and clinics have long struggled to recruit doctors. In rural areas, there are roughly 13 physicians — of any kind — per 100,000 people, compared with 31 in urban areas, according to the National Rural Health Association.
Doctors and other medical providers can be enticed by programs that repay their school loans if they work in a rural area. Some medical schools have programs designed specifically for students who plan to practice in rural or underserved communities. Another way to make treatment more accessible in rural areas is to expand the responsibilities of nurse practitioners, physician assistants and even paramedics.
Lost Rivers relies on nurse practitioners and physician assistants to provide care for patients in the clinics and the hospital. In addition to Browne, the medical center has four part-time primary care physicians, some who live hours away and come in once a week. Various specialists, including a cardiologist and an orthopedist, also rotate into the medical center’s outpatient clinics about once a month. And an MRI machine gets driven to the hospital once a week.
Tim Tomlinson, a podiatrist who lives in Twin Falls and drives 100 miles to Arco once a week, spent a recent morning seeing a lineup of patients. One was a man who had to have a toe amputated after a horse stepped on his foot, another a diabetic who needed a skin graft checked on his foot.
Tomlinson said he’s gotten paid late before, and he has seen the hospital nearly shut down more than once. But he keeps coming because he has developed a practice — and he thinks its important patients have access to specialty care. Lost Rivers isn’t unique in its difficulties, he noted. “All those small towns are struggling as young people move out, leaving mostly old people,” he said. “That puts a drain on the hospitals.”
Patients are living longer with chronic diseases now, so the demand for elderly care is only going to increase. If not the rural clinics and hospitals, Tomlinson said, “who’s going to deliver it?”
Even with the decline in the nation’s rural population, many people are rooted in rural America because of family or because they like the outdoors and a slower pace of life. One of them is Gene Davies, who has lived in Arco more than 60 years, runs a mechanic shop straight out of a different era. Handwritten signs sit on a wooden chair next to the door: “Gone to Dr.” “Be back tomorrow.” “Hope to be back Monday.”
Davies said he appreciates the remoteness of the region. “I ain’t got no plans to go anywhere else,” he said. “I’ve seen enough of the other world. I don’t want it.”
Rosenkrance, the cattle farmer, said she’s not going anywhere, either. She’s been coming to the hospital since she was a child, when she ran through the halls while her father worked in the pharmacy. Now her husband teases her about having a standing reservation in the emergency room.
Just before discharging Rosenkrance, nurse Celeste Parson told her she needed to rest physically and mentally. The accident had left her with a concussion, a lacerated ear and a black eye. Then Parson issued her the most important instruction: Don’t do anything that could cause another blow to the head.
“We would really like you to rest up for at least a week,” Parson said. “But the doctor knows for you, two or three days is more realistic.”
As she grabbed an ice pack and her purse, Rosenkrance reflected on the importance of Lost Rivers for residents across the whole valley.
“This hospital is a big deal,” she said. “It’s saved a lot of lives.”
Dale Maxwell, who was recently named president and CEO of Presbyterian Healthcare Services, based in Albuquerque, N.M. discussed with Hospitals & Health Networks his system’s innovative initiatives, including its patient-navigation model and its increasing use of telemedicine to treat its far-flung rural population.
He said that the system must grow to be sustainable over the coming years, saying:
“We have two really important initiatives from the growth standpoint right now. One in Santa Fe, where we’re building a medical center to serve the northern part of New Mexico which will open in 2018. Growing outside of New Mexico is also an important strategic option for us. Over the past 30 years, we’ve built expertise and knowledge in integrating the financing of care into the delivery of care; we’re in a great position to export that knowledge and expertise outside of New Mexico and partner with other provider systems to ensure the move toward value-based care and population health. And in North Carolina, we’re partnering with 11 systems to bid on Medicaid as they roll out managed care and move away from a fee-for-service model.”
On the patient-navigation model:
“We started this model in 2010. It came out of the early work of looking at the data and analytics, where patients received care and the overall cost of that care. As we looked at the emergency department, it was a great opportunity to change how care is delivered and be more specific about delivering care in the right place at the right time.
“As patients enter our ED, each one has a medical screening. If the screening determines that the patient is not in an emergency status, the or she is navigated to a more appropriate care setting. That could be a referral to urgent care or a primary care facility.
“The goal is to establish that patient with a primary care physician; then they can begin to manage the patient for future services. It’s taking a very expensive ED visit and translating it into a less costly clinic visit. More importantly, the management of the patient in the long term is going to provide better care to the patient and, overall, decrease the cost of care.”
On the system’s home health care, including palliative services:
” The unique piece of this is that it’s embedded into our patient-centered medical home, similar to other services like behavioral health or pharmacy management services. This aligns the care across the continuum with all of the care teams, so it’s not isolated in any respect.”
On telehealth:
“We have a couple of, I would say, established and successful programs. One is our Telecritical care program. Intensivists here in Albuquerque take care of patients at two of our regional facilities through video. By using the care teams at the point of care and a physician in Albuquerque, we’re able to deliver the necessary care for the patient. He or she receives the highest-quality physicians, is able to stay in the community and doesn’t need to be transferred to a different facility, so that really benefits members.”
A new survey from digital-venture firm Rock Health says that America is at a “tipping point” for adopting digital health tools.
The company’s second annual survey of what it called more than 4,000 “representative” U.S. adults found that 46 percent are now active digital health adopters, up from 19 percent in 2015. An active adopter is seen as someone who has used three or more categories of digital health tools, such as telemedicine and wearables. Meanwhile, the company said, the number who are non-adopters dropped to 12 percent this year from 20 percent in 2015. {We at CMG suspect that these figures may be exaggerated because of Rock’s vested interest in having people use digital devices.}
“We’re at a tipping point, and we’ll continue to see growth in this,” says Ashlee Adams, vice president of partnerships and strategies for Rock Health and an author of the study.
In what might surprise many people, rural hospitals, despite all their problems and the fact that few are affiliated with medical schools, did better on average than their urban counterparts in Medicare’s value-based purchasing program, says a new report by the U.S. Department of Health & Human Services.
The program rewards or penalizes acute-care hospitals based on the quality of care. The report said rural hospitals did better than urban ones on patient experience as well as on efficiency and costs.
HHS said “while rural hospitals face unique barriers, they have a number of strengths that might enable successful participation in and good performance under delivery reform efforts.”
The report linked rural hospitals’ strong showing in part to the care coordination needed among a relatively small (compared to urban and suburban hospitals) group of providers and noted that a broad range of services often share the same physical site or owner, which tends to increase efficiency.
It also said the increasingly effective use of telemedicine, particularly useful for treating widely dispersed populations in the countryside, might be improving care in rural hospitals.
On the day abdominal pain and nausea struck Jessica Christianson at the office, she discovered how far telemedicine has come.
Rushing to a large kiosk in the lobby of the Palm Beach County School District’s administrative building where she works, Christianson, 29, consulted a nurse practitioner in Miami via two-way video. The nurse examined her remotely, using a stethoscope and other instruments connected to the computer station. Then, she recommended Christianson seek an ultrasound elsewhere to check for a possible liver problem stemming from an intestinal infection.
The cost: $15. She might have paid $50 at an urgent-care center.
The ultrasound that Christianson got later that day confirmed the nurse practitioner’s diagnosis.
“Without the kiosk I probably would have waited to get care and that could have made things worse,” she said.
Endorsements such as Christianson’s demonstrate how technology and positive consumer experiences are lending momentum to telemedicine’s adoption in the workplace.
Less than a decade ago, telemedicine was mainly used by hospitals and clinics for secure doctor-to-doctor consultations. But today, telemedicine has become a more common method for patients to receive routine care at home or wherever they are — often on their cellphones or personal computers.
In the past several years, a growing number of employers have provided insurance coverage for telemedicine services letting employees connect with a physician by phone using both voice and video. One limitation of such phone-based services is physicians cannot always obtain basic vital signs such as blood pressure and heart rate.
That’s where telemedicine kiosks offer an advantage. Hundreds of employers — often supported by their health insurers — now have them installed in the workplaces, according to consultants and two telemedicine companies that make kiosks, American Well and Computerized Screening, Inc.
Employers and insurers see the kiosks as a pathway to delivering quality care, reducing lost productivity due to time spent traveling and waiting for care, and saving money by avoiding costlier visits to emergency rooms and urgent care facilities.
Jet Blue Airways is adding a kiosk later this year for its employees at John F. Kennedy International Airport in New York. Other big employers providing kiosks in the workplace include the city of Kansas City, Mo.
Large health insurers such as Anthem and UnitedHealthcare are promoting telemedicine’s next wave by testing the kiosks at worksites where they have contracts.
“This technology should make it more affordable for employers of many sizes,” Jesser said.Anthem has installed 34 kiosks at 20 employers in the past 18 months. John Jesser, an Anthem vice president, said kiosks are a good option for employers too small or disinclined to invest hundreds of thousands of dollars in creating an on-site clinic with doctors and nurses on standby.
Kiosks are typically used for the same maladies that lead people to see a physician or seek urgent care — colds, sore throats, upper respiratory problems, earaches and pink eye. Telemedicine doctors or nurse practitioners can email prescriptions to clients’ local pharmacies. Employees often pay either nothing or no more than $15 per session, far less than they would pay with insurance at a doctor’s office, an urgent care clinic or an emergency room.
Despite kiosks’ growing use in telemedicine, it’s unclear whether they will be supplanted as smartphones, personal computers and tablets enable people toaccess health care anywhere with a Wi-Fi connection or cell service. Some employers already offer kiosk and personal device options, including MBS Textbook Exchange in Columbia, Mo., which has 1,000 workers.
Workplace kiosks’ appeal is they are quiet, private spaces to seek care. Consumers can get their ailments diagnosed remotely because the kiosks are equipped with familiar doctors’ office instruments such as blood pressure cuffs, thermometers, pulse oximeters and other tools that peer into eyes, ears and mouths. The instrument readings, pictures and sounds are seen and heard immediately by a doctor or nurse practitioner.
“The kiosk gives the doctor more tools to diagnose a wider range of conditions,” Anthem’s Jesser said.
The downside is that the machines cost $15,000 to $60,000 apiece, which may still be too much for some employers.
“Telemedicine kiosks look promising and may still take off, but I don’t see explosive growth,” said Victor Camlek, principal analyst with Frost & Sullivan, a research firm.
While kiosks are now found in more workplaces, usage is still relatively low because employees are not sure how they work, said Allan Khoury, a senior consultant with Willis Towers Watson.
Employers’ experiences are mixed.
Officials in Kansas City, Mo., estimate that the kiosk placed in city hall almost a year ago has saved the local government at least $28,000. That’s what Kansas City hasn’t spent because employees and dependents chose the telemedicine option instead of an in-person doctor visit. The city also estimates it has gained hundreds of productive work hours — that’s the time employees saved by not leaving work to see a doctor.
In contrast, fewer than 175 of the 2,000 employees at the Palm Beach County School District headquarters have used the kiosk there in its first year, said Dianne Howard, director of risk management.
Howard remains hopeful: “This is the future of health care.”
The district’s kiosk was supplied at no cost by UnitedHealthcare, as part of a test also involving two other employers in Florida.
Those kiosks connect employees to nurse practitioners at Nicklaus Children’s Hospital in Miami. The hospital employs an attendant at each kiosk location to help workers register and use some of the instruments, such as the stethoscope.
Other telemedicine kiosks, such as those made by America Well, are designed to be totally self-service for employees. They also offer users immediate access to a health care provider. American Well has deployed about 200 kiosks and is in midst of rolling out 500 more, mostly to employers, the company said. It also places kiosks in retail outlets and hospitals.
Telemedicine’s increasing sophistication is winning over some traditional-minded physicians.
The WEA Trust in Madison, Wis., a nonprofit that offers health coverage to public employers, installed a kiosk for the benefit of its 250 workers last fall.
Tim Bartholow, M.D., a family doctor by training and chief medical officer for the trust, said he was cautious about physicians treating patients they haven’t seen in person. After observing employees using it, Bartholow is convinced it can help them get good care.
“I don’t think telemedicine is making a doctor being on site quite agnostic, but it is certainly reducing the premium on being in the same space as the patient,” Bartholow said.
Insurers declare they are moving carefully, too, recognizing that telemedicine has its limits and they must depend on practitioners to tell patients when they have to see a doctor — in person.
“We have to rely on their experience and judgment,” Jesser said.
The telemedicine war may be calming down in Texas.
It has been a year since the Lone Star State imposed controversial restrictions on telemedicine, in part because of pressure from physicians worried that telemedicine might cut into their income. The action spawned a lawsuit from Teladoc Inc., based in Dallas.
Teladoc is a year-old telehealth company that uses telephone and videoconferencing technology to provide on-demand remote medical care via mobile devices, the Internet, video and phone.
The state last year banned physicians from making diagnoses or prescribing drugs over the telephone or Internet for any patient with whom they didn’t have an existing in-person relationship.
But now The Texas Tribune reports that some healthcare and business groups, including Teladoc, have met about “modernizing our telemedicine statutes and reducing the regulatory footprint governing the provision of telemedicine services.” The groups hope to reach a compromise to submit to the Texas legislature next year.
Malignant melanoma, the most dangerous skin cancer.
A recent study in JAMA Dermatology of 16 online telemedicine companies found that some of the online physicians misdiagnosed skin cancer, herpes, and syphilis and prescribed medication without taking patients’ medical history.
Another example of the clinical limits of telemedicine, whatever its cost-and-time-saving allures to patients and insurers.
Non-exclusive agreements with the likes of such nonhospital enterprises as CVS MinuteClinics, with their big customer bases and low financial risk.
Joint ventures that may appeal to providers willing to make a capital investment in return for more ownership and equal representation on boards of directors.
Leased-space arrangements in which hospital systems operate convenient-care clinics themselves, but within a retail space.
Telemedicine partnerships that might include healthcare providers paying a fee for provide services and technology in return for branding and referrals.
