"Malpractice" or the "future of medicine"?


Covid-19 is turning skeptical doctors into telehealth believers

Direct-to-consumer telehealth companies aim to provide accessible, speedy, stigma-free care without a physical exam. Some patients and physicians remain skeptical.

When urologist Ranjith Ramasamy first heard about men's telehealth startups Hims and Roman, he was worried.

It was 2017 and Ramasamy, the director of Male Reproductive Medicine and Surgery at the University of Miami, feared he was going to lose patients to telemedicine providers without appropriate certifications or specialty training.

"When I first heard [of these startups], I thought this was going to be bad for the field," Ramasamy tells Inverse. "This is going to be a disservice to our patients. And more importantly, I thought there was going to be some harm involved on the patient side."

Direct-to-consumer telehealth companies aim to provide accessible, speedy, stigma-free care for everything from erectile dysfunction to herpes — without a physical exam. However, troubled by the risks of mistakes and misdiagnoses, as well as privacy breaches, some physicians and patients have been skeptical.

Then Covid-19 hit. In a pandemic that makes a visit to the doctor riskier than ever before, telehealth has seemingly come to the rescue, promising efficient care from the safety of home.

Out of necessity, many physicians have incorporated telemedicine into their practices — seeing about 50 to 175 times the number of patients virtually than they did pre-pandemic. Hims and Roman are especially experiencing unprecedented demand and expanding their offerings beyond sexual medicine into primary care and mental health.

However, while telemedicine solves some major barriers to care — especially for men — it creates new problems, too. With a serious lack of regulation and data, it's unclear whether telehealth will truly revolutionize health care and live up to its lofty promises. When a doctor's visit goes virtual, what gets lost in translation?

"This whole approach of saying, 'Everything is malpractice with telehealth or I have to see all patients in person' is incorrect," Ramasamy says. "But I also think saying, 'We don't need to see anybody in person. We can do everything in men's health with telehealth' is incorrect. A combined approach is probably what's going to win at the end."

In March, the U.S. government temporarily relaxed telehealth restrictions, enabling Medicare reimbursements, lifted geographic licensing barriers for remote care, and waived privacy rules set by the Health Insurance Portability and Accountability Act (HIPAA). On August 3rd, the Trump administration proposed changes extending access to telehealth permanently.

These shifts allowed doctors and patients to communicate via FaceTime, Skype, and Zoom, and in turn, telemedicine boomed.

Before the pandemic, telehealth usage was at the fringe of care consumption, making up about 3 billion dollars of health care spending in 2019. Now, analysts predict virtual visits could account for up to 250 billion, or about 20 percent, of what Medicare, Medicaid, and commercial insurers spend on outpatient, office, and home health visits.

Marc Goldstein, a urologist and the director of the Center for Male Reproductive Medicine and Microsurgery at the NewYork-Presbyterian Hospital Weill Cornell Medical Center, tells Inverse his first reaction to men's telehealth companies was resolute: “This is malpractice.”

"There are relatively rare exceptions where a patient could be given a prescription without an actual physical exam," Goldstein tells Inverse, "but that's really the exception, not the rule."

Ranjith Ramasamy conducting a telehealth visit amid the Covid-19 pandemic.

Ranjith Ramasamy

The pandemic has forced doctors like Goldstein and Ramasamy to shake off their reservations and start seeing their own patients virtually. That these visits proved to be ultimately useful shocked them and suggested that telehealth has utility for certain men’s health conditions, screenings, or follow-up visits.

Goldstein was "pleasantly surprised" by how much of a complete medical history he could get through telemedicine, while Ramasamy now thinks "telemedicine is one of the few positives that came out of the Covid-19 pandemic."

It's not about replacing primary care docs or specialists, the physicians say. It’s about offering a supplement to in-person care — carefully and at patients' convenience.

Patrick Carroll is a family physician and the chief medical officer of Hims and Hers, both operated by Hims, Inc. He sees what's happening presently as the "inflection point of telemedicine."

"Even traditional providers who may not have bought into telemedicine before and actually had to deliver it that way have realized that, 'Wow, this is a very useful, powerful modality that I need to incorporate into my traditional practice,'" Carroll tells Inverse.

Prior to Hims and Roman launching, urologist Peter Stahl grew increasingly aware of the "overly burdensome" nature of his practice. People were waiting weeks for an appointment, then waiting an hour at the office for an "eight-minute visit," Stahl recalls.

"It's not that the care wasn't good," Stahl tells Inverse. "Everything was getting done, but it was very hectic and burdensome to patients."

Stahl is the director of male reproductive and sexual medicine at NewYork-Presbyterian Hospital/Columbia University Medical Center and a urology advisor to Hims. He sees patients in New York City, but these lags in care are prevalent elsewhere. Eighty percent of the rural United States is estimated to be medically underserved, creating "health care deserts" where primary care doctors, surgeons, and specialists can be hard to find. Researchers forecast this problem will deepen in the next decade, predicting a shortage of up to 122,000 primary care physicians by 2032.

"A combined approach is probably what's going to win at the end."

Physicians and specialists like Stahl are stretched thin, seeing up to 50 patients each day. That means the time of patient visits shrinks, and both doctors and patients can feel dissatisfied with care.

"You come out of medical school and you are very hopeful and excited about having like a really long, detailed 30-minute or 60-minute visit with someone that includes a lot of talking and the physical exam," Stahl explains. "And at least in some aspects of subspecialty care, the reality just looks a lot different."

That's where telehealth comes in. Telemedicine – whether it's asynchronous (a health care provider reviews messages, images, and data shared by a patient, then diagnoses and prescribes an issue a la the Hims/ Roman model) or synchronous (a real-time telephone or video patient visit with a provider) — can restructure both patients' and clinicians' time.

In an ideal world, Stahl says, telehealth can enable providers to practice the kind of medicine they once dreamed about: in-depth, in-person visits unburdened by simple, straightforward cases. Ultimately, the type of visits patients want, where people get what they need "in the most efficient way possible," Stahl says.

Carroll, the Hims and Hers CMO, was drawn to telehealth because he also wanted to provide more convenient care for patients.

"It is access to care 24 hours a day, seven days a week; it's really on the patient's or customer's schedule and not on the doctor's schedule," Carroll says. "It provides the opportunity to reach people in a very frictionless, convenient way and to offer very high-quality services.”

While these telehealth startups may be convenient, they may not be cost-effective. While patients utilizing telehealth services through their doctor can now get reimbursed by their insurance, those currently relying on Hims, Roman, and other direct-to-consumer startups will not. These companies still say their services save patients money and time, enabling them to skip an in-person visit or trip to the pharmacy and avoid copays.

An online visit with Roman costs $15, while Hims charges a membership fee from $10 to $17. However, as Bloomberg reported in 2019, the medications prescribed through these platforms are often marked up, sometimes as much as six times the typical price of the same drug.

Roman sells a 20 mg dose of generic Viagra for $2, while Hims sells it for $3 a pill. Pharmacies buy the drug for about 15 cents a pill, and patients can find them at drugstores through online discount programs for as cheap as 41 cents a pill.

Although telehealth has been around for years, it hasn't been accessed this widely before. To date, there haven't been any comprehensive studies or analyses of which conditions are best treated by telemedicine. There also haven't been any large-scale studies documenting error rates of telehealth platforms. Whether telemedicine will truly streamline health care remains to be seen.

"This is a whole new area, and they're sneaking in before there are any regulations," Goldstein says. Goldstein adds that, despite his own positive experience using telehealth in his practice, he and his colleagues are "appalled" at what is going on. Goldstein plans to facilitate a specialty-wide discussion about how to make men's telehealth safer.

"You cannot prescribe anything for the patient regarding his reproductive function, whether it's erectile dysfunction or testicular dysfunction, without examining the testicles, without examining the organ that's responsible for fertility and responsible for testosterone level," Goldstein says.

Dr. Marc Goldstein. He plans to facilitate a specialty-wide discussion about how to make men's telehealth safer.

Goldstein is increasingly confident treating patients through Cornell's telemedicine system, even without seeing patients in person. But he questions whether prescribing doctors on Hims or Roman have the experience and training to do a thorough job. At Hims, prescribing physicians are typically primary care doctors or nurse practitioners who follow Hims' clinical sexual medicine guidelines, but they are not required to be specialized in the conditions they are treating.

When asked about the level of oversight, Stahl said he can't think of any clinical guidelines related to treating specific conditions via telehealth. He’s working on drafting some broad-use urology telemedicine guidelines now and argues the physical exam should be a test employed thoughtfully, in specific cases when "you're suspicious or when it's warranted."

Stahl and Carroll say that Hims' repetitive, standardized nature enables detailed quality control. In the past year, Carroll and his team have been able to review 8,000 patient encounters and an automated system fastidiously tracks physicians’ prescribing and diagnostic behavior. If anything is awry, the physician is required to complete additional training, and sometimes, disinvited to see patients on the platform.

"It's sort of the pilot with a checklist mode, where really there's no option not to ask all the right questions and get all the right safety information — because you're not asking the questions. The technology is asking questions and demanding answers to them," Stahl says. In contrast, synchronous face-to-face telehealth is currently "only as good as the doctor providing it," he argues.

Meanwhile, Ramasamy theorizes that the "cookie-cutter approach" utilized by many telehealth platforms relying on questionnaires and verifications of patient answers could apply to the majority of patients. But he argues there's still a risk of missing something important to diagnosis or treatment — something that would have been caught in-person.

"Reading a room and picking up body language is so important, and I worry how we’ll compensate in telemedicine interfaces."

Internist Vishal Khetpal also questions what may be lost when a doctor's visit goes virtual. He is a resident physician at Brown University Medicine and the author of a 2019 telehealth opinion piece in Undark.

Khetpal and Ramasamy agree that, ideally, telehealth would be optional after patients and providers connect in person if deemed medically appropriate. Patient-doctor relationships are optimal when there's some familiarity.

"Reading a room and picking up body language is so important, and I worry how we’ll compensate in telemedicine interfaces," Khetpal tells Inverse.

Khetpal also worries asynchronous telehealth like Hims and Roman may lead to the gradual fragmentation of primary care.

"As an internist, I find it extraordinarily difficult to take apart the diagnoses of my patients in the way that these companies do with their products. They effectively are all interwoven with one another," Khetpal says.

"An algorithm may be able to determine whether or not it’s safe for a patient to start a new medication, but I think a person is still better equipped to connect the entirety of a patient’s general health to the specific health problem and design an actionable plan that is personalized to the patient."

Every physician Inverse consulted acknowledged that telemedicine is appropriate for some, not all medical issues. If you're thinking of trying telehealth, it's recommended to investigate and learn about the health provider you are consulting. Check out their specialty, background, and experience treating conditions or symptoms you are dealing with, Ramasamy advises.

Where telehealth is particularly useful, Khetpal says, is counseling for issues like substance use, chronic medical conditions, and preventative screenings. And, ideally, these sessions "involve a patient and physician who know each other and already have a good underlying relationship.”

As long as the Covid-19 pandemic surges on, telehealth isn’t likely to slow down. In 2019, just 11 percent of Americans reported using telehealth. Now, it's 46 percent of Americans. As Carroll notes, this is the inflection point for telemedicine. It's also the point where telehealth companies will have to decide whether or not they want to change their services to satisfy the old guard.

"The Covid-19 pandemic has really just forced mass exposure for doctors and patients to telehealth," Stahl says. "Patients and doctors alike are recognizing that telehealth certainly has a place in medicine. I think that it's never going to be the same."

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