The Rise of Telehealth

The Rise of Telehealth

Telehealth has become a necessity during the pandemic. But its promises to increase access will fall apart if it becomes yet another profit center in a consolidated healthcare system.

A spine surgeon in Boston conducting a telehealth appointment with a patient ( Jessica Rinaldi/The Boston Globe via Getty Images)

I was sitting beside my grandmother in the Westchester Medical Center ICU—she’d had a heart attack, complicated by a bad fall and by her lung cancer—when a nurse appeared on the TV hanging in the corner.

My grandmother, gurgling through a ventilator, waved. The nurse waved back.  

“Do you see that too?” she asked me. We both jumped as the nurse blared into the room: “Theodora? How are you feeling?” 

The nurse, we established after some back and forth, was not an apparition. She was a real person located in a central room on the hospital’s campus, and she looked in on all of the patients in the ICU.  

We would know if the camera was on if the screen was on, she explained. My grandmother, ever lewd, leaned closer to me to say: “They’re perverts. They watch people in their sleep.”

The eHealth Center, according to its website, is staffed 24/7 by “healthcare professionals” who “serve remotely as a second set of eyes for the dedicated bedside physicians and nurses” in the network’s ten hospitals spanning the Hudson Valley in New York State. Vital signs from patients in its 1,700 beds are transmitted to the central hub, where “Sophisticated technology, such as audio and video equipment, including camera and microphone, enable communication with patients, their families and other healthcare providers.”

Our experience with the TV nurse occurred a few months before the onset of the coronavirus pandemic—when ventilators became scarce, when it became a rare luxury to sit bedside, and when capital began to scoop up telehealth ideas in earnest.

Since March, major firms such as Microsoft, Lenovo, and Alphabet have thrown resources into the development of platforms like Cloud for Healthcare and services like video chat. Smaller companies have been soaring in the stock market, receiving massive cash infusions, and citing huge influxes of user-patients. A McKinsey report predicts that, by the end of the pandemic, up to $250 billion of healthcare revenue in the United States will be “virtualized,” up from $3 billion before COVID-19.

Doctor On Demand, a telemedicine company cofounded by Dr. Phil that employs more than 700 doctors, announced a $75 million Series D funding round on July 8, 2020, adding to investments by Venrock, Goldman Sachs, and Google Ventures. “We have just been climbing and climbing since March,” CEO Hill Ferguson told Forbes, adding that appointments are up 139 percent. Part of this increase is due to a widening net. People enrolled in a Walmart medical plan can see a doctor over video chat through Doctor On Demand for “as low as $0.” In mid-May, the company announced it would provide for Medicare Part B recipients—a population consisting of some 33 million seniors who are vulnerable to the increased risks of exposure to coronavirus while visiting a doctor’s office.  

“The role for telehealth is obvious in certain situations—there’s no question that in the middle of a pandemic it’s good to be able to speak to a physician without going into the office. No one is denying that,” said Adam Gaffney, President of Physicians for a National Health Program (and a contributor to Dissent). “But there is a concern that it opens the door for the continued corporatization of healthcare . . . telehealth is very ripe for corporate takeovers.”

Telehealth, with its veneer of start-up innovation, has become a darling in political discourse, boardrooms, and stock portfolios. And during the pandemic, when telehealth providers can offer technical solutions in an emergency, companies have sought to argue for their massive expansion in terms of social justice—the growth of telehealth, this argument goes, increases access to healthcare, so is good for us all. In fact, the growth of telehealth has fallen neatly into place with an increasingly consolidated corporate healthcare system: the acquisition- and merger-driven behemoths that put profit margins and executive salaries over the quality of care for patients. As money pours into the healthcare sector, we should be wary of claims that our health crisis can be solved by tech-capitalists, while Medicare for All—a proposal that would truly expand healthcare access—has been sidelined as a political and practical impossibility.

The consolidation is already beginning. On Wednesday, August 5, Teladoc announced that it would acquire Livongo, another telehealth rival, for $18.5 billion. On August 3, just two days before, President Trump signed an executive order to expand telehealth. Focused on rural areas, the order instructs various federal departments to improve infrastructure for telehealth, develop new payment methods, and permanently expand Medicare coverage before it is stopped by the end of the state of emergency. “Prior to the pandemic, telehealth was fine, but it wasn’t anything raging, and I guess one of the only good things that we’ve gotten out of this horrible situation is that telehealth has been increased,” Trump said at a press conference.

Telehealth has widespread support on both sides of the aisle. On July 16, members of the newly formed bipartisan Congressional Telehealth Caucus introduced the “Protecting Access to Post-Covid-19 Telehealth Act of 2020.” The bill—which Trump’s executive order makes more likely to pass—would solidify the changes the pandemic has forced. It would do away with limitations on Medicare and Medicaid’s allowances to reimburse telehealth services, including an existing rule that banned Medicare recipients from accessing services from home and geographic restrictions that limit access to begin with.

Industry players praised the move. “The legislation would once and for all remove arbitrary geographic restrictions on all Medicare telehealth services and ensure access for patients for whom traditional office visits don’t always work,” eHealth Initiative CEO Jennifer Covich Bordenick said in a statement. Even before the bill’s introduction, over 200 groups, including Doctor On Demand, Talkspace, Teladoc, the American Psychiatric Association, and a smattering of universities, cosigned a letter to congressional leaders urging that the “temporary flexibilities extended to health systems and providers” be expanded beyond the public health emergency declaration. “Absent additional action from Congress,” they wrote, “Medicare beneficiaries will abruptly lose access to nearly all recently expanded coverage of telehealth.”

 Caitlin Donovan of the National Patient Advocate Foundation is cautiously encouraged by such developments, which she points out have the potential to make more types of healthcare available to more people. The average amount of financial assistance patients request, she said, is just $22, for gas to get to appointments. Telehealth is one such solution to the issue of transportation. Still, she said, “It has to be financially accessible and it also needs infrastructure—broadband, devices with which to access the internet.”

 “The problems with telehealth go back to our original sin of healthcare in this country: the amount we charge,” Donovan said. This is the appeal of telehealth: the possibility for a modest expansion in what Medicare covers and the obvious practicality of being able to contact a doctor when and where you need to. But as the future of telehealth is shaped by the vortex of capital and lobbying, more questions will emerge about cost, about efficacy, and about labor. How these questions are answered will determine whether telehealth becomes a real way to expand access, or just another medical service that puts profit over genuine care. Will more eICU centers lead to fewer people on the floor seeing patients “bedside”? Will insurance providers reimburse less for telehealth visits than in-person visits, as research professor Sabrina Corlette warned the New York Times? Will it be employed as a cost-saving measure, or used to justify decreased funding to rural hospitals? Will it serve as a driving wedge for further privatization?

One form of telehealth familiar to subway-riders, podcast-listeners, and YouTube-watchers is teletherapy, especially the for-profit apps that advertise daily texting with a therapist and less-frequent video chats.

One such company is Talkspace, which matches users with a licensed therapist and then offers unlimited texting 24/7—“Though,” their website reads, “if you’re sending messages at 3 AM, you might have to wait until they wake up!” The basic service costs $65 a week, significantly lower than typical out-of-pocket rates for therapy sessions, which hover over $100 and vary widely geographically. For additional fees, Talkspace offers couples therapy, video calls, and psychiatric services (a recent addition). For those services, which include prescribing medications, an initial evaluation by video is $199, and follow-up sessions are $125. Talkspace does not accept Medicare or Medicaid but does participate with some employee-assistance programs. A review on Glassdoor, reflecting the sentiment of many therapists, states that the “Pay is a mockery.”  

BetterHelp, a competitor, has comparable rates and does not accept Medicare, Medicaid, or other insurance. Neither platform fulfills court-mandated therapy requirements. Unlike TalkSpace, BetterHelp does not offer psychiatric services; the website advises that “if you have been advised to be in psychological supervision or psychiatric care,” the service is not right for you. On the whole, there is a lack of clarity around the exact nature of their services. As Marie Fang says in a YouTube video she posted about her experience applying to work for the platform, she wondered “if our professional liability insurance would cover ‘counselor services’ as rendered through BetterHelp.” Her inability to find an answer to that question online led her to more questions, including whether she could be asked to talk to someone in a different state than the one she was licensed in: “Who protects the client? Does client privilege apply? Who protects the therapist? Does BetterHelp have the right to actually sell client information?”

Regardless of these concerns, teletherapy isn’t going anywhere. Studies of patients suffering from depression have found no significant difference between in-person and teletherapy sessions, and 2017 research found text-based therapy “an acceptable and clinically beneficial medium.” It could have intuitive benefits for some, such as those who are agoraphobic or who live in an area where few therapists are available. Some therapists, of course, decry the practice, citing the invaluable therapeutic medium of the in-person exchange. But a majority of therapists were thrust into all-remote work with the onset of the pandemic, using FaceTime, Zoom, or encrypted platforms such as Doxy for their sessions. These practices are themselves a form of telehealth—and many private practitioners indicate that they will continue to offer them in the future. Likewise, both Talkspace and BetterHelp point to recent spurts in sign-ups that parallel those of non-therapeutic telemedicine.

The growth of telehealth, in all its permutations—eICUs, with their nurses on TV; digital health platforms; on-demand virtual visits; teletherapy by text—has accelerated dramatically during the COVID-19 crisis. Yet, as Gaffney points out, what’s being offered might not be quite the earth-shattering innovation its champions make it out to be: “Speaking to a doctor on a telephone has been around since the invention of the telephone. It’s not exactly as radical as it is being described. The difference now is that patients might be on the hook for calls that might have otherwise been covered by the standard appointment costs.”

If telehealth is accelerating, then, it can also be understood as an accelerator of the corporatization of healthcare, and everything that comes with it: investment in for-profit companies, hidden costs for patients, attempts to squeeze more out of workers, device-driven care. Companies dominate at every level of medicine, from pharmacies to insurance providers to cancer treatment and surgical centers. These companies often cannibalize each other to form conglomerates so large they make a mockery of the tenets of competition and choice promoted by opponents of Medicare for All. For-profit healthcare leads to worse health outcomes: research shows that patients have a higher risk of dying in for-profit hospitals than in not-for-profit hospitals, and the same goes for for-profit dialysis chains.

“The for-profit system also leads to the dangerous overuse of technologies and pharmaceuticals to address health problems in order to increase corporate profits while putting patients at risk of injury, side effects, and addiction,” writes Dorothy Roberts in an essay in We Own the Future: Democratic Socialism—American Style. Furthermore, if telehealth is adopted as a standard form of care, there is good reason to worry it would deepen existing racism in healthcare provision. As Roberts writes,

Black patients’ vulnerability to harmful biases and stereotypes is manifested . . . in the undertreatment of pain based on commonly held myths that black people as a race feel less pain, exaggerate their pain, or are predisposed to drug addiction. A 2016 study conducted at the University of Virginia School of Medicine found “a substantial number of white medical students and residents hold false beliefs about biological differences between blacks and whites”—beliefs such as black people have thicker skin and less sensitive nerve endings than white people—and these beliefs predict racial bias in pain perception and treatment.

 Virtual visits, which would require more self-reporting and judgements made through perception rather than measured vital signs, could make the effects of those biases worse. Furthermore, as Certified Languages International CEO Kristin Quinlan told Axios, “Too few telehealth platforms are working to build in services for video interpretation” for the nearly 10 percent of the U.S. population with limited proficiency in English. Brick-and-mortar hospitals that receive any federal funding, by contrast, are required to provide translation services.

A staffer at a clinic for low-income children with asthma in Washington, D.C., described to Dissent how checkups, which were moved to a HIPAA-compliant version of Zoom during quarantine, faced a multitude of limitations—bad Wi-Fi connections in homes, limited access to broadband, and data charges that would be too high if they used their phones for the video calls. That’s not to mention the diagnostic limits; over Zoom, doctors couldn’t listen to patients’ breathing or examine their tonsils, both critical measures in their practice. In these cases, it is easy to foresee how more telehealth could lead to worse care.

“Using technology that already exists and devices that most people have in their homes, medical practice over the internet can result in faster diagnoses and treatments, increase the efficiency of care and reduce patient stress,” wrote columnist Jane Brody in the New York Times in May. But when the entire U.S. health system is shot through with for-profit and private entities, we should be skeptical of claims that support for telehealth expansion is primarily driven by concern for patients. Given the obvious downsides of telemedicine once alternatives are safely available, it has the potential to become a cost-saving mechanism—and an investment driver—after the pandemic recedes.

Telehealth isn’t going anywhere, according to Gaffney. “The question is if we are going to allow the unrivaled acceleration of the corporatization of healthcare. . . . The real resource is the nurses and the doctors, the healthcare providers,” he continued. “The resource is not in terms of the app. The resource is the people.”

Technological developments out of Silicon Valley often obscure real workers and basic economic transactions while creating massive wealth. It will be a travesty if this model floods the healthcare sector. The healthcare professional on the TV was not an apparition, and her wave was not a figment of my grandmother’s imagination; your therapist, answering your flurry of texts, is not a robot, though you may have your doubts. Telehealth itself is not the revolution it promises to be—it has existed for at least a century. Nor is it a bad thing in itself. Through its corporate implementation, however, it threatens to deepen the inequities of our healthcare system at a moment when creating an alternative is more important than ever.   

Lyra Walsh Fuchs is an editorial assistant at Dissent.

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