Why the utilization conversation in telemedicine is bigger than dollars and cents



A study published in Health Affairs and conducted by the RAND Corporation made a big splash this week with a bold claim: That telemedicine doesn’t actually reduce healthcare costs because the increased convenience leads to increased utilization, which ultimately costs more than in-person care would have.

The study looked at claims data from a cohort of 300,000 employees with access to Teladoc through their employer. Researchers compared a cohort of telemedicine users to a cohort of non-telemedicine users and found that in the telemedicine users, visits to primary care doctors barely decreased, meaning that the Teladoc visits were mostly additive (visits that otherwise would not have occurred), rather than substitutive (visits that otherwise would have occurred in person). They found that 88 percent of visits were additive, and only 12 percent replaced in-person visits. The result: telemedicine cost the payer $45 per patient more than a plan without telemedicine would have.

Health Affairs and RAND are some of the most well-respected names in health policy research, and rightly so. The methodology of the study was strong, the sample size was large, and the conclusion bears careful consideration, and follow-up research. But there’s also a lot to be said in response to the study, both by those who think the data is misleading and by those who think there’s a bigger picture here than the one the study paints.

First of all, as might be expected, telemedicine vendors have some quibbles with the study.

Teladoc CEO Jason Gorevic says that Teladoc surveys every patient at the moment they seek care and asks them what they would have done if telemedicine wasn’t available. Their data — even for that particular cohort — is almost exactly the reverse of the Health Affairs study: 87 percent said they would have gone somewhere else to get care, while only 13 percent was additional utilization. The RAND study dismisses that survey data as subject to a number of psychological biases, but Teladoc’s approach of trusting the patients themselves over statistical modeling certainly has an appeal. And for what it’s worth, Gorevic added, the payer that was the subject of the study has not only continued to use Teladoc, but has added more members to the platform in the intervening years.

Roy Schoenberg, the CEO of Teladoc competitor American Well, pointed out that the data is at least four years old at this point, and changes in the technology and level of consumer trust in the technology since then might make the data invalid (not to mention that the study is of phone visits and a lot of telemedicine is offered by video). While in 2013 people were using telemedicine tentatively and still visiting their primary care provider when they were really concerned, now that the technology is more established and more often offered by their provider, consumers might be more likely to use telemedicine as a replacement.

Both Schoenberg and Gorevic pointed to other research studies and published case studies that have shown the opposite of the Health Affairs study, or at least shown that overall telemedicine saves money. Research and consulting firm Advisory Board has some other thoughts about possible shortcomings.

I also spoke with health economist and blogger Jane Sarasohn-Kahn, of Health Populi. The biggest omission, to her mind, is that the study doesn’t consider the longterm impact of increased utilization of preventative care. If those extra visits keep patients out of the hospital because they catch a respiratory infection early and it prevents a more serious condition like pneumonia, those savings could make up for the cost of extra visits.

“The big question that goes unanswered in this study is what costs were averted because people used cheaper telehealth,” Sarasohn-Kahn said. “So all they’re looking at is the numerator, not the denominator. But on the other end, we don’t know what people saved by taking advantage of this quote-unquote ‘extra session’. We have to look at the whole equation, and this study only looks at one side of the equation.”

This becomes especially apparent, she added, when we consider populations for whom the alternative to telemedicine is not a primary care doctor (the cohort in the Health Affairs study was fairly affluent), but an emergency room or urgent care center, which represent a much steeper jump in price. In those cases, the one telemedicine visit that catches a big problem down the road makes up for a lot of visits that don’t.

Sarasohn-Kahn’s plea to look at the bigger picture raises some even larger ideological considerations.

The whole idea of “overutilization” includes some implicit assumptions: One, that there is some appropriate amount of healthcare a person should seek, and, two, that that amount is whatever people were seeking under the status quo of in-person visits. Is it paternalistic to suppose patients can’t be trusted to know when they should and shouldn’t see a doctor? Rather than concluding that patients are overusing telemedicine because it’s convenient, could we just as easily conclude from the same data that up until now patients have been underusing their doctor because seeing them was too cumbersome?

“Talking to a doctor is not a recreational activity,” is how Teladoc’s Gorevic put it. “People talk to a doctor when they’re sick, and when they need care, and when they need help.”

More than that, evaluating telemedicine in a vacuum is just as problematic as comparing it only to the status quo. The healthcare system of the future will very likely be a tiered one, where telemedicine is only one of a series of escalating steps. Patients might start with an automated app or online symptom-checker, move to a chat or messaging with a nurse or care manager, see a doctor by telemedicine if that isn’t enough, and come in in person only as a last resort. If every step of that process is weighted equally as “a doctor visit”, certainly technology will appear to increase the number of doctor visits. But in reality, it will decrease the strain on the system where it matters most.

“One of the biggest mistakes of the way people think of telehealth is they think of it as just another way for people to get to the same kind of healthcare,” Schoenberg told me. “If you think of it that way, overutilization is going to be an immediate byproduct and it’s going to be a terrible thing. But the perspective around telehealth of most of the payers and most of the brokers and most of the employers out there is that it changes the way patients utilize healthcare and they become more discerning, almost intuitively, about what can be handled by basic forms of triage before they have to go to a telehealth visit.”

Payers and providers who are using or considering telemedicine shouldn’t ignore the Health Affairs study, or any other research that calls the perceived benefits of new technology into question. But they should recognize that utilization is a broad, complicated issue with many facets. And that when it comes to innovation, investigators always run the risk of judging next year’s technology by last year’s metrics.


Connie’s comments: With increased utilization of telemedicine and interaction with doctors, emergencies and acute health issues are averted, health consumers live longer with quality of life and in the long run telemedicine can save lives and reduce total health cost.

Web and mobile appointment with doctors for less than 5 min

We are looking for investors to compete with teladoc. Email motherhealth@gmail.com


Teladoc’s membership swelled to 17.5 million, a 43 percent increase year-over-year. The company recorded 310,467 visits for the fourth quarter, up 68 percent from Q4 2015. There were 952,081 for the year, representing a 65 percent jump. Total revenue was $37.4 million for the fourth quarter of 2016, representing an increase of 65 percent from last year. Similarly, the full year revenue was up by 59 percent, bringing Teladoc’s 2016 total to $123.2 million

“During the year, we completed our company’s 2 millionth telehealth visit, representing savings through our clients in the U.S. healthcare system of over $900 million,” Gorevic said on the call.  “As context, it took us about 12 years to reach our first million visits, while only 14 months for our second million. This clearly signals the inflection point in overall telehealth adoption.”


Senior care and predictive medicine



Anxiety risk scale and Senior care

The above anxiety risk scale is used by doctors to evaluate behavior health issues especially in older adults as brought about by trauma, sickness, chronic stress, death in the family, being divorced or widowed, other health issues.

  • When taking care of older adults, know the signs of any behavioral health issues and other health issues to ensure they are addressed early to prevent emergencies and to be proactive.
  • To fully help older adults with health issues, we need to mobilize an integrated care team to ensure that all areas are covered, a caregiver to take care 24/7 when needed, a podiatrists to care for the feet, an acupuncturists, a physical therapist, primary care doctor, a neurologists and other specialists or health care providers.
  • Ensure that medications are monitored for side effects and adverse reactions.
  • When transferring from nursing home to homes, ensure that oxygen tanks, medications and hospital beds are ready based on health requirements of the older adults.
  • And also to ensure that the house is seniors safe to avoid falls and other emergencies.

For 24/7 Alzheimer care in the bay area, call 408-854-1883 or email motherhealth@gmail.com

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Predictive medicine

In the future, predictive medicine can help us be more proactive.

Predictive medicine is a field of medicine that entails predicting the probability of disease and instituting preventive measures in order to either prevent the disease altogether or significantly decrease its impact upon the patient (such as by preventing mortality or limiting morbidity).[1] While different prediction methodologies exist, such as genomics, proteomics, and cytomics, the most fundamental way to predict future disease is based on genetics. Although proteomics and cytomics allow for the early detection of disease, much of the time those detect biological markers that exist because a disease process has already started. However, comprehensive genetic testing (such as through the use of DNA arrays or full genome sequencing) allows for the estimation of disease risk years to decades before any disease even exists, or even whether a healthy fetus is at higher risk for developing a disease in adolescence or adulthood. Individuals who are more susceptible to disease in the future can be offered lifestyle advice or medication with the aim of preventing the predicted illness.

Current genetic testing guidelines supported by the health care professionals discourage purely predictive genetic testing of minors until they are competent to understand the relevancy of genetic screening so as to allow them to participate in the decision about whether or not it is appropriate for them.[2] Genetic screening of newborns and children in the field of predictive medicine is deemed appropriate if there is a compelling clinical reason to do so, such as the availability of prevention or treatment as a child that would prevent future disease.

Why the need for complete DNA sequence at 50yrs of age?

This is the time that there is some damage in our DNA structure as a result of the environment, health issues and aging. We can use this genetic information to predict any health issues in the coming years.

Email motherhealth@gmail.com for gene-based diet for older adults and for senior concierge in the bay area.

Coming soon is our website http://www.avatarcare.net to bring precision medicine, predictive medicine and telemedicine to all.


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Top ten research priorities for the management of Parkinson’s

The top ten research priorities for the management of Parkinson’s:

  1. What treatments are helpful for reducing balance problems and falls in people with Parkinson’s?
  2. What approaches are helpful for reducing stress and anxiety in people with Parkinson’s?
  3. What treatments are helpful for reducing dyskinesias (involuntary movements, which are a side effect of some medications) in people with Parkinson’s?
  4. Is it possible to identify different types of Parkinson’s, eg, tremor dominant? And can we develop treatments to address these different types?
  5. What best treats dementia in people with Parkinson’s?
  6. What best treats mild cognitive problems such as memory loss, lack of concentration, indecision and slowed thinking in people with Parkinson’s?
  7. What is the best method of monitoring a person with Parkinson’s response to treatments?
  8. What is helpful for improving the quality of sleep in people with Parkinson’s?
  9. What helps improve the dexterity (fine motor skills or coordination of small muscle movements) of people with Parkinson’s so they can do up buttons, use computers, phones, remote controls etc?
  10. What treatments are helpful in reducing urinary problems (urgency, irritable bladder, incontinence) in people with Parkinson’s?


University of East Anglia

Telemedicine Improves Access to Specialty Parkinson’s Care

An additional Penn study being presented at the AAN meeting examined use of telemedicine visits to increase access to specialty care for Parkinson’s patients, in an effort to help remove barriers to specialty care experienced by many patients who live far from care or have disabilities that make it difficult to travel. A Penn Medicine team led by Jayne Wilkinson, MD, and Meredith Spindler, MD, conducted a randomized controlled trial using video telemedicine in the patient’s home or at a facility near the patient (in this case, VA Community Based Outpatient Clinics (CBOCs), connecting them to a neurologist specializing in movement disorders and Parkinson’s disease, based at the Parkinson’s Disease Research, Education, and Clinical Center (PADRECC) at the Philadelphia VA Medical Center. Early results demonstrate that the process of using telemedicine for Parkinson’s specialty care is feasible, provided similar quality of life, care and communication, and significantly decreased travel. This is the largest study to evaluate telemedicine in this Parkinson’s patient population.

Dr. Wilkinson and Spindler


University of Pennsylvania School of Medicine

Join 25,000 people in helping redefine health with health concierge and precision medicine.


Predictive medicine for longevity and cancer cure with actionable health data





Join 25,000 people in helping redefine health with health concierge and precision medicine.


A platform for health consumers to stop cancer early and collaborate with health care teams

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Short Summary

  • I am Connie Dello Buono, health author and blogger at www.careme.live ( soon http://www.avatarcare.net )
    Since 2000, I have cared for seniors with cancer, Alzheimer’s and Parkinsons.
    My passion is help reduce chronic care costs, health education and personalize medicine using telemedicine.
  • This campaign will address cancer health issues, identifying root causes early, connecting with doctors real time, access to telemedicine and tele-clinics, matching providers using mobile application and a health application that will hep reduce chronic care costs.
  • As contributors, you will help achieve our goal of reducing chronic care costs thru telemedicine, personalize medicine and a health mobile application serving all population groups.

Motherhealth Inc

Management Team

  • Maddalena Adorno PhD, CTO. She is a professor at Stanford University Institute for Stem Cells and Regenerative Medicine
  • Connie Dello Buono, CEO. She is a health author and completed her B.S in Mathematics with minor in Chemistry at Adamson University, Manila Philippines

What We Need & What You Get

  • $5000 of the funds will go to the mobile application developers and marketers.
  • Your unique perks will be a lifetime discount, 20%, in the many health apps that will come out of this first phase of the product.

The Impact

  • Avatarcare.net or Motherhealth aims to help health consumers navigate in their health issues and collaborations with health care professionals by providing a platform for them to order their genetic and lab tests, join in health care forums, learn about health care issues and prevention, set up appointment with others and health care teams, find and post health care jobs, video chats with doctors and a health concierge provided online and in the future, via a mobile application.
  • Globally, we can now correlate health data and provide valuable insights to all, scientists and the population.
  • Since 2000, I have been educating the public on health, wrote an ebook on women’s health, was pharmacy tech instructor, a senior care administrator and care provider, and quality assurance in many biotech and medical device companies in the USA.