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Aside from whatever a visit to the doctor costs you in money, it also costs you in time. A lot of it. Can we make that better? That's the topic of this week's Healthcare Triage.

This episode was adapted from a column friend-of-the-show Austin Frakt wrote for the Upshot. Links to references and further reading can be found there:

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Aside from whatever a visit to the doctor costs you in money, it also costs you in time.  A lot of it.  Can we make that better?  With the help of my colleague Austin Frakt, we answer that in this week's Healthcare Triage.  


Special thanks to Austin Frakt who wrote The Upshot column this episode was adapted from.

End to end, the travel of waiting time for a doctor's appointment can take several hours, often disrupting work or school.  Only 17% of it, 20 minutes on average, is spent actually seeing the doctor, according to a study by the University of Pittsburgh physician (?~0:37) and colleagues at the Harvard Medical School and the Rand Corporation.

Each year, Americans spend 2.4 billion hours making doctor visits.  At average wages, that's worth more than $52 billion, equivalent to the total working time and income of 1.2 million people.  On average, we pay $32 when visiting a doctor (our insurers pay nearly $250), but separately, the value of our time adds up to more, $43 according to Dr. (?~1:03)'s study.

For certain kinds of healthcare, there may be a better way.  Long after electronic communication have revolutionized other services, like preparing taxes, booking travel, and banking, e-mails, phone calls, video chats, and other telemedicine applications are gradually supplementing or replacing some types of office visits.

Telemedicine holds the promise of giving some of our time back and it may have other advantages.  Care delivered in this way requires no travel and if one waits at all, it's at home or work, not at a doctor's office.  In an era of Facetime and Skype, patients are starting to expect more convenient access to doctors.  Go watch our episode on retail clinics, for instance.

The vast majority of patients report that they want to be able to communicate with their doctors by e-mail.  Perhaps for this reason, the market for telemedicine is growing rapidly.  Some insurers are embracing it.  For example, Kaiser Permanente of Northern California offers its patients 10-15 minute telephone visits as well as a secure website where patients can message back and forth with their doctors.  Half of its visits are virtual and its executive director and CEO reported that 80% of its dermatology cases involving rashes are resolved by digital communication.  

The Veteran's Health Administration's growing telemedicine program is credited with reducing time patients spend in the hospital.  The average number of days to schedule an appointment fell 31% in a rural Alaskan community when Ear, Nose, and Throat Care services were provided by telemedicine.

Telemedicine may be more convenient, but is it worse care?  The research indicates that on the whole, it isn't.   A systematic review published in 2015 found that heart failure patients receiving telemedicine died at no higher rates than those not receiving it.  Outcomes of care were the same for mental health, substance abuse, and dermatology patients who used telemedicine relative to those who didn't.

The review also found that telemedicine helped people with diabetes maintain better control of their blood sugar and that it led to lower cholesterol and blood pressure.  Other reviews came to similar conclusions.  Telemedicine can also bring care to rural locations.  Certain kinds of a strokes are effectively treated with intravenous clot-busting drugs that require expertise to deliver properly.  That expertise may be unavailable at some rural hospitals, but it can be conveyed by video conference to emergency department physicians.  It's called telestroke, and a 2010 systematic review found it reduces mortality.

Of course, telemedicine can't work for every health issue.  Physicians often need close, in-person examination of patients, but a review of medical records of older patients found that 38% of inpatient visits, including 27% of emergency department visits, might have been replaced with telemedicine.

Sure, some physicians and nurses may be reluctant to offer it.  Out of concern that they'll be inundated by e-mails and phone calls for which they won't be compensated and for some of which might not be medically relevant.  However, a survey of clinicians who use secure electronic messaging with patients at a Veteran's Health Administration medical center reported that message volume was manageable and content was appropriate, consistent with other studies.

Another hitch is that some insurers resist it, perhaps feeling increased cost for no additional health benefits.  Insurance coverage for telemedicine is spotty.  Medicare covers it only when the patient is hosted in a rural clinic or hospital.  Some Medicare Advantage plans, on the other hand, cover telemedicine more broadly.  Only 21 states require private insurers to cover video visits, but many do not.  State Medicaid programs vary in paying for telemedicine, and states are inconsistent in allowing out of state physicians to offer telemedicine services.  There are continuing debates in state houses and in Congress on whether to expand coverage for telemedicine and doctors' groups are considering its ethics and liability risks.  

The biggest hurdle may be state medical boards.  Idaho's medical licensing board punished a doctor for prescribing an antibiotic over the phone, fining her $10,000 and forbidding her for providing telemedicine, and some states have laws that restrict telemedicine, for instance requiring the patients and doctors have established in-person relationships.  These laws have drawn lawsuits charging that they illegally restrict competition.

Georgia's state medical board requires a face-to-face encounter before telemedicine can be delivered while Ohio's does not.  A study by Julia Adler (?~5:18), an assistant professor at the School of Information and the School of Public Health at the University of Michigan found that such state laws and medical board requirements influence the extent of telemedicine use in hospitals.  While 70% or more hospitals in Maine, South Dakota, Arkansas, and Alaska use telemedicine, only 13% in Utah and none in Rhode Island do, for instance.

In a passionate commentary on the establishment's hesitancy to embrace telemedicine, David Asch, a University of Pennsylvania physician, pointed out that the inconvenience of face-to-face care limits its use but arbitrarily and invisibly.  The costs of waiting and travel time and those borne by rural populations with poor access to in-person care don't appear on the books.  

"The innovation that telemedicine promises is not just doing the same thing remotely," Dr. Asch wrote, "But awakening us to the many things that we thought required face to face contact but actually do not."

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