By Amanda Koehn
A patient goes to a primary care appointment and the doctor notices a spot on the patient’s arm. Maybe it’s a mole, a cyst—even a zit. The doctor isn’t sure so the patient needs to see a dermatologist.
The new appointment comes with a six-week wait, not to mention the time and monetary expenses of getting to the doctor. Then there’s the possibility that the spot will disappear by the time of the appointment. In that case, the patient will be sent home, only to repeat the whole ritual if the spot flares up again.
But some patients going to the Cook County Health and Hospitals System, which covers most of Chicago, avoid this whole process by using telehealth technology and software called eConsult.
“With eConsult we can get a picture over to the dermatologist,” said John Prendergast, operations director of patient support at CCHHS. The dermatologist gets the picture immediately and can decide whether the patient needs an appointment in person, a prescription, or nothing at all.
This kind of health tech may seem costly and unattainable by doctors serving low-income populations. Many telehealth apps and web services are paid out of pocket or with specialized insurance. However, more and more apps for both physical and mental health are becoming available for another population: people who can’t afford traditional healthcare. In fact, the patient Prendergast described used Medicaid.
CCHHS is testing a pilot program where nearly 35,000 Medicaid patients and their doctors have access to eConsult. It lets primary care doctors and specialists chat and send pictures back and forth. Thus far, Prendergast said an online dialogue can prevent the need for an appointment in 30 percent of consultations. The specialist then has more time in the schedule to see the remaining 70 percent who require an office appointment.
“We can’t have patients waiting in queues and waiting to be seen.…when it’s just a question, let’s get the questions answered,” Prendergast said.
Although CCHHS works with just the eConsult web service right now, telehealth apps are expanding around the U.S. and more and more let patients chat with doctors themselves. Researchers, developers and Medicaid coordinators are just beginning to explore how apps can shift the way patients at all income levels experience healthcare.
Smartphone adoption transforms telehealth
Telehealth, a term coined in the 1970s, refers to any healthcare overseen from a remote location, using technology. Many people assume telehealth is for people in rural locations who can’t visit a local doctor or therapist, Prendergast said. But the near-universal adoption of smartphones and hundreds of thousands of health apps are bringing telehealth to everybody.
More than two-thirds of Americans have a smartphone with a data plan. Nearly 20 percent of all people with Internet access have it only on their phones. Lower income people, who once lacked Internet access, often fall into that category.
“We’ve seen these populations kind of do the jump over to technology. It was the case 10 years ago when people were working mostly on desktop computers that you saw a big digital divide between different [socioeconomic groups], where people just didn’t have access to computers,” said Stephen Schueller, a clinical psychologist and Internet interventions researcher at Northwestern University.
Access to healthcare has historically posed a problem for people on Medicaid, said Keri Christensen, a project manager at Medical Home Network. MHN is a nonprofit, accountable care organization in Chicago that bridges a healthcare system between patients, doctors and social services. MHN gives Medicaid patients a central healthcare resource and often works with CCHHS.
“Working a very low income hourly wage type of job, [it] can be a real problem for a patient to need to take off at a specific time, that they do not get to decide, for a medical appointment, “ Christensen said. “If that’s the only appointment available in two months, they need to take [it], but that may cause problems at work.”
People on Medicaid often live far away from high-quality health services, so they may have a long bus or train ride to a doctor’s office. In Chicago as elsewhere, wait times for specialists are long because only a limited number of providers accept Medicaid, or even Medicare, patients. However, apps help bridge the gap. Christensen said that since CCHHS started using eConsult, patients can get an appointment with a specialist in a week instead of 60 days.
“The physicians really like it as well,” Christensen said. Tests are arranged in eConsult and completed at the primary care facility prior to the appointment. Specialists can then spend more time talking to patients instead of gathering tests.
Dr. Charles Edoigiawerie is a family physician and medical director at the Englewood Health Center, which receives around 15,000 patient visits per year. He shared the story of one patient who he noticed had an enlarged prostate, which could be a sign of prostate cancer. Typically, this patient would have to anxiously wait weeks for an appointment with a specialist. However, with eConsult, Edoigiawerie consulted with a specialist within an hour. The specialist quickly confirmed that the patient would indeed need a specialty appointment and was seen within a couple days.
Edoigiawerie said the eConsult system has been vital, “just so many times.”
Prendergast said using eConsult also takes pressure off the patient, since the primary care physician can better manage appointments and tests for the patient digitally.
“We are willing to add providers, which we have never done before,” Prendergast said. “A good problem that we would have is to add a dermatology provider just for eConsult,” he added.
Video chatting apps and mental health
A report from 2015 estimated there are about 165,000 health apps on the market today, with varying levels of evidence to support the benefits of their services. While a large percent of apps on the market are primarily for wellness, nearly 15,000 apps are for a specific ailment. Of this group, apps for mental health, diabetes and blood and circulatory disease are the most numerous.
Nearly a third are devoted to mental health. The Breakthrough web service, based in Redwood City, California, provides a video interface for clients to meet with therapists online.
In 2014, Breakthrough’s services became covered by Medicaid in Illinois, Nebraska and Florida. Breakthrough is now testing an app that offers the same services as the website. Ashley Gibson, vice president of product at Breakthrough, said an app is easier for clients to use because everything they need is in one portal.
“As long as they can download that app, once you are in that app, you are in that experience,” Gibson said.
But few states cover teletherapy for mental health conditions under Medicaid. Neeta Crawford, vice president of marketing at Breakthrough, said companies do not decide whether to accept Medicaid—it’s usually at the hands of lobbyists to push the state to require or block coverage for mental health services. Breakthrough is covered by Medicaid because they had a good relationship with managed care organizations that were looking for a provider, Crawford said.
“It’s definitely one of those areas where everyone realizes it’s a huge opportunity, but we are just starting to dip our toe into it right now,” Gibson said. “And also adoption is a challenge, because you are dealing with a very conservative market.”
Medicaid patients often face a greater stigma associated with going to therapy than their higher income counterparts, for a variety of social and economic reasons. “I certainly think more affluent markets are more accepting of mental health and therapy. Certain demographics, it’s almost, like, expected,” Gibson said. “Telehealth really helps with that because it gives you privacy…you don’t have to wait with a bunch of random people in a waiting room.”
Implications of infusing tech and healthcare
While providing telehealth to low-income patients increases care and makes interacting with a doctor less of a hassle, challenges involving implementation and adoption remain, said sources from both Breakthrough and CCHHS.
“It’s really tough to grow a business in healthcare because of the complexities. You have to make revenue and even if we gave this away free, it would still be tough because of the rules and regulations,” Gibson said, specifically in reference to treating Medicaid clients.
Tech companies can typically make the same, if not a larger profit with their already-existing markets: young, generally healthy people who either pay out of pocket or through employer-based insurance.
For example, the HealthTap app provides a WebMD-like search engine, online chatting and video consults with doctors, and a personalized feed of health information. Doctors can also prescribe medicines digitally. While use of the search engine is free, consults and the personalized feed are only offered to people who either pay out of pocket, or those with employer insurance that covers HealthTap specifically.
Jarod Hector, head of marketing and communications at HealthTap, said the app service hopes to eventually branch out to patients on Medicaid or with private insurance but it’s not in the foreseeable future.
“We want the people who have the most difficult time accessing [healthcare], to have an easy time accessing. And that varies on multiple factors, age, education level,” said Hector.
Leaders at HealthTap agreed that getting top physicians in the network is a good way to stand out from other health apps. Schueller also said apps should be “vetted” by major healthcare companies (Kaiser, Aetna) for further ease of access for consumers.
Schueller questions whether the tech sphere is the right place for the telehealth shift to happen, as opposed to hospitals and research institutions. He says the goal of tech companies is usually to make a popular product, but they are a step removed from fully understanding the complexity of healthcare access. Apps should first, solve issues for those with the most difficulty accessing healthcare. For this reason, researchers may be better suited to create and test apps because their incentive is to mend a dysfunctional healthcare system, which they see on a day-to-day basis.
“I think you are going to need people who are dedicated to that cause, because I think a lot of tech companies are kind of focused on revenue as opposed to the public good,” Schueller said.
Schueller became interested in behavioral intervention technologies during a postdoctoral fellowship at the University of California, San Francisco. “We had a very kind of humanitarian bent with the kind of work we did online,” he said. “We really saw Internet interventions, mobile apps, as a way to make healthcare a universal right for people.” Now living and working in Chicago, Schueller says he has seen mental health services for people on Medicaid shut down in part due to the budget crisis. Wait lists are typically four to six months long.
Schueller said researchers often talk about models where a mental health app offers some paid services and some free services. That way, the paid services bring in money to fund the overall venture and people who can’t afford to pay can access the other components of the app. Schueller is among those who believe research institutions should host the apps.
However, the tech industry is not likely to give up its seat. Gibson said that Silicon Valley companies are becoming more and more interested in telehealth because they see the inefficiencies of the healthcare system and think their innovations can improve it. Prendergast agreed.
“Follow the money—all the different companies have a piece of it—Google is interested, Microsoft is interested…everyone is collaborating and the venture capitalist in all of them are getting a piece of the action,” Prendergast said.
Apps for all
In the case of CCHHS and other telehealth services covered by Medicaid,
Christensen said it’s important to address who Medicaid patients really are. Young adults who became insured by Medicaid under the Affordable Care Act are one such group, Christensen said. Like most young people, they are tech savvy, even if they don’t own computers and only have internet access on a smartphone.
Schueller’s Northwestern research team is testing the mental health benefits of giving iPhones to homeless youth. Using the phones, the youths receive cognitive behavioral therapy to treat anxiety and depression.
Each month in the study, the young adults will have three appointments with a therapist via the app. Between appointments, they can check in with the therapist through the app as often as they like, or can text or call. Based on preliminary data from focus groups, the researchers expect their mental health will improve substantially. The study will take around a year to complete.
“We can’t expect that they are going to be able to come into our brick and mortar psychological services, so we need to think about ways to be more flexible to create services that they might actually be able to access,” Schueller said.
For Prendergast and CCHHS, the next step is installing retinal screening cameras at primary care facilities. Retinal cameras are used to screen patients for retinopathy, or eye damage related to diabetes that can lead to blindness. This way, patients don’t have to wait until an ophthalmologist has an open appointment for the test—primary care doctors can just send along the pictures via eConsult.
“We are in our infancy, but we are still plugging away,” Prendergast said. “As the industry expands we want to expand with it.”