Can Telemedicine Be Both Cost Efficient and High Quality?
Health insurance companies are encouraging patients to turn to apps and virtual visits to save time and money, but some patients end up not getting the care they need

Terena Bell

Feb. 27, 2018 (U.S. News & World Report) — Last month, Jennifer McMurrain of Bartlesville, Oklahoma, didn't go to the doctor – she requested one by app. "I had horrible sinus pressure in my head," she said. "I knew immediately it was a sinus infection and to get over it I'd need a round of antibiotics and prednisone." So McMurrain relied on Teladoc, a telemedicine provider that partners with Aetna, her insurance provider. She told the doctor she was asthmatic and that if she didn't receive treatment, her medical history indicated the infection would settle in her chest. 

The doctor refused to help; instead of a prescription, McMurrain got "a lecture on how people use antibiotics too much." Then she got sicker. The sinus infection moved into her lungs, she missed four days of work, and her husband fell ill as well.

In 2017, Teladoc treated 24 million patients. Ninety-two percent, the company claims, were pleased. Some subscribe to the service directly, but others, like McMurrain, access Teledoc through their health insurance. For providers like Aetna, telemedicine offers cost savings and increased access to care. But some consumers wonder how their insurance companies make sure telemedicine partners provide quality care – and what, if any, accountability measures are in place when they don't.

At Aetna, Head of Network Product and Telemedicine Strategies David Hildebrand says their Teladoc contract includes "performance guarantees" for hold times, call length, and member satisfaction. He mentions no guarantees regarding standard of care. When it comes to whether physicians have the credentials and experience Teladoc claims, Hildebrand says, "We trust them and contractually they're obligated."

This trust has propelled the partnership for seven years. When Aetna chose Teladoc in 2011, the telemedicine provider was one of two on the market. "We found them to be the largest and most experienced at that time," Hildebrand explains, noting email security practices were also considered. 

Today, the American Telemedicine Association says around 200 providers are in operation, but Aetna doesn't plan to change partners any time soon. While Hildebrand says they "continually look at all available options," changing providers is difficult for a company of Aetna's size, especially when long-term vendors become partners. 

"Over the years we've expanded the offering and the partnership to additional services," he explains. "We've rolled out behavioral health with them. We've rolled out dermatology, as well as a caregiver program. And we have the opportunity to partner with them and look at building out new products and services. We look at the data together. We look at the communications to our members together, and try to understand them, and provide information at the right time to them, provide them resources to our customers."

"We're really trying to innovate... and look at figuring out where the next evolution of telemedicine will go," he continues. "And it's easier to do that when you have an incumbent that is as much invested in supporting your members as you are."

"We're happy with the partnership that we have; our customers are happy with it." he adds. How does he know they're happy? Teladoc surveys say so. 

"We do a follow-up with everybody at 72 hours to see if they've gotten better or if they needed to go see another provider," explains Teladoc CEO Jason Gorevic, specifying that everybody really does mean everybody. "Every consumer gets at least an electronic follow up after 72 hours." That's where the 92 percent pleased statistic comes from.

That's what's supposed to happen, but in reality, everyone doesn't receive a survey. McMurrain didn't. Neither did fellow Aetna customer Kim Guthrie of Olney, Texas, who called Teladoc last month with a urinary tract infection. "The doctor told me within three minutes that she couldn't treat me," Guthrie says. "She said I needed to go to my regular doctor." 

After refusing service, Teladoc next refused to issue a refund. "It's just very frustrating," Guthrie adds, explaining that, as a teacher, she has a fixed income. "Teladoc makes money either way," she continues, adding that she thinks "they are screwing people over."

"Obviously, I can't respond to an individual case without looking into it, but I'm happy to," Gorevic responded after being asked about Guthrie and others' claims.

While patients like Guthrie and McMurrain end up having to pay for both a Teladoc consultation and a visit to their regular doctor, Gorevic says financial savings are one of telemedicine's big draws. The exact amount charged varies by plan, but he says the typical Teladoc appointment costs insurance companies "about $45. That contrasts to about $120 to $125 for a typical office visit, somewhere in the neighborhood of $175 for an urgent care visit, and north of $1,000 for an emergency room visit." Overall, Teladoc-funded studies show each call saves providers an average of $472.

While Teladoc does keep Aetna's costs down, Hildebrand says customers aren't required to see teledoctors before or instead of their primary care physicians: "We don't have a benefit plan that says they need to use this service before they do something else. It is set up there [for] convenience, to provide access, and allow them to access the service when they feel it's most important to them." He does, however, note telemedicine services are priced "at a lower cost share to try to encourage utilization."

This holds true industry-wide. Oscar Health customers can access the insurance provider's Doctor on Call service, which directs to Teladoc and other vendors, for free. UnitedHealthcare works with Doctor on Demand and American Well. UnitedHealthcare Director of Communications Lynne High says, "The total cost of a visit is under $50, with the member's portion of the cost determined by their benefit design." 

"Consumers throughout their entire lives are shifting to the on demand economy, whether it's booking travel or shopping for groceries or buying shoes," Teladoc's Gorevic says, adding "healthcare fits right in with the rest of the economy. Consumers see this as a more-convenient, more-timely way to get care. It also happens to be a more cost-effective way to get care."

But no matter how cost-effective care gets, providing it – and addressing people's health concerns – isn't as simple as buying milk. Khan Shoieb, head of communications for Oscar Health, says when a customer experiences a problem due to quality of care, employees "direct the member to address their concerns specifically with Teladoc" as opposed to Oscar, stressing that Oscar and Teladoc "are two separate entities." Hildebrand says Aetna's contract with Teladoc outlines processes for escalation and issue resolution, but open communication is important, especially from people like McMurrain and Guthrie, who don't make it into Teladoc's surveys.. 

"If there's a problem," Hildebrand says, "we would want to know about it and address it right away."

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