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Does the rise of digital care spell trouble for primary care practices?


The telehealth boom begs the question: Will the expansion of hospital-based services wind up pulling patients-and revenue-away from primary care practices?

It’s no wonder telehealth has grown in popularity. Patients hop on their device of choice, connect with a provider via phone call or video conference and win out by saving on time, travel and cost. But patients and the digital providers serving them aren’t the only ones who see the potential. Hospitals and health systems are increasingly taking medical care online as well.


Further reading: Is there a real time advantage to telemedicine?


Cleveland Clinic, for example, has announced intentions of adding to its consumer telehealth program. The nonprofit academic medical center and one of the largest hospitals in the nation began its program in 2014 to provide visits for acute conditions such as cough and cold, flu, asthma, rashes and minor back or shoulder pain.

Now there are plans to add dermatology and behavioral health to its offerings and intentions to expand telehealth from 14 to 25 states by the end of the year. After that, the next big move will likely include the treatment of chronic conditions like diabetes and high blood pressure. Cleveland Clinic plans to continue to use American Well as its software vendor while shifting over to the use of its own providers to conduct the visits.

It is one example of a larger movement underway.

When American Well launched in 2006, its business focused mainly on direct-to-consumer offerings. Now, the telehealth giant and others like it- MDLive, Teladoc, and Doctor on Demand-as well as a smattering of smaller startups have set their sights on the perceived final frontier.

American Well doubled its book of business in this realm last year and now serves over 70 health systems that together have more than 700 hospitals, and Teladoc has gone from working with 60 clients in 2016 to over 120 health systems or hospitals now.


Related: How do physicians care for the digitally isolated?


This expansion doesn’t appear to be tapering off, either. The number of U.S. health systems with consumer-service telehealth programs is on track to nearly double from 2016 to 2018, according to findings from the Hospital & Health Systems 2016 Consumer Telehealth Benchmark Survey, conducted by Teladoc in partnership with Becker’s Healthcare.

Next: Does digital replace in-person?


Does digital replace in-person?

The telehealth boom begs the question: Will the expansion of hospital-based services wind up pulling patients-and revenue-away from primary care practices?

“I can see how private practice specialists might be impacted if they do not have telehealth capability,” says Paul J. Reiss, MD, partner at Evergreen Family Health, “but most primary care docs in general have all the business they can get.” Because of that, he doesn’t foresee any real cause for concern.


Health IT advice: The key to making virtual visits a digital success


Similarly, a study recently published in Health Affairs indicates that there isn’t a need to sound the alarm bells just yet. The findings estimate that only 12 percent of digital visits replaced in-person visits while 88 percent represented the new use of medical services. The figures suggest that the convenience of telehealth encourages people to seek assistance for minor issues that would not have prompted them to drive to a brick-and-mortar facility.

“Based on our study, it doesn’t seem like the expansion of these services is really going to take business away from physicians because they wouldn’t have seen it anyway,” says lead author J. Scott Ashwood, Ph.D., associate policy researcher at RAND Corporation.

And to the extent that these are replacement visits, it might be beneficial in the sense that it could free doctors up to focus on more complex cases. It depends on how their visit flow works, Ashwood points out, but if doctors don’t have to spend 10 minutes talking to a patient with a sore throat, then that could be 10 minutes devoted to another with a chronic or more complex condition.

There are limitations to the study, which examined utilization data of 300,000 people enrolled in the Blue Shield of California Health Maintenance Organization plan offered by the California Public Employees Retirement System (CalPERS). Teledoc was the only telehealth provider examined and the study focused on simple acute conditions only. In addition, the patients had commercial insurance, and it is possible that usage rates could differ among those with high-deductible plans, government coverage or no insurance.


Related reading: What are small practices saying about telemedicine?


Jason Gorevic, CEO at Teladoc, points out that the study doesn’t align with more recent Teladoc data. According to figures from 2016, only 13 percent of Teladoc visits represent new medical use. The RAND study relies on older information, and some elements have changed since then, such as the technology and the rate at which services are being adopted.

Next: Improving accessibility


Improving accessibility

There is potential for hospital-based telemedicine services to reduce some of the volume that would go to primary care, says Jesse M. Pines, MD, MBA, MSCE, director of the Center for Healthcare Innovation and Policy Research at George Washington University School of Medicine and Health Sciences.

“Some people have to wait long periods of time for appointments,” he says, “and they vote with their feet-or they vote with their computer now.” Telemedicine meets patients where they are, and so do emergency departments. How can primary care practices become more accessible? Answering that question could be the key for those looking to get ahead of this trend and reduce any potential substitution effect that could grow over time.


In case you missed it: Virtual visits boost primary care outcomes


That said, it is useful to consider all this within the bigger picture of healthcare. Telemedicine is a tiny piece of the overall market at this point, Pines says. The largest portion consists of acute visits to doctors’ offices. Next in line are urgent care and emergency department visits, followed by retail clinic visits. At the bottom are these digital visits that are beginning to creep up in recent years.

“I think that the key is not to put your head in the sand and to say this is not coming, but to engage in whatever your hospital and community are doing and to try to get involved because this telemedicine will only increase in the future,” he adds. “That’s really the way to sort of hedge your bets when it comes to telemedicine is to become a telemedicine provider and participate.”


Paul Nicolaus is a freelance writer specializing in health and medicine. Learn more at

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